Fill and Sign the Certificate of Physician as to Competency of an Individual Form

Certificate of Physician as to Competency of an Individual NOTE: This certificate will be used in legal proceeding. The information this certificate contains must be based on your personal examination of the patient. Please address each issue contained in the certificate including the nature, cause, extent and probable duration of any disability that your patient may have which interferes with his/her ability to make responsible decisions about health care, food, clothing, shelter or property. It is possible that your testimony about this information may be required at a hearing. Thank you for your concern and cooperation. Name of Patient _____________________________________________________ Address of Patient ___________________________________________________ I, __________________ (Name of Physician) , located at _______________________ _____________________________________________________ (office address) am a _________ (year) graduate of ____________________________________________ ______________________________________________________________________ (Name and Address of Medical School) . The telephone number of the school is _________________. I am licensed to practice medicine/psychology/social work (circle one) in the United States in the following states: (list) __________________________________________ I am Board Certified in (e.g., Psychiatry) __________________. My specialty is (e.g., Psychiatry) ___________________. I have known this patient for (period of time) _____________________________ . The history of my involvement with the patient is the following (describe) ___________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _____________________________________________________________________ . I personally examined __________________ (Name of Patient) on _______________ (date) . The examination lasted approximately ____________ (time) . I performed or ordered the following tests: (list) ________________________________ ______________________________________________________________________ ______________________________________________________________________ The patient exhibited the following symptoms:  Physical: (list and describe) _________________________________________  Mental: (list and describe) __________________________________________ Based on tests and my examination of the patient, it is my professional opinion that ___________________________ (Name of Patient) : [ ] does have a physical or mental disability that interferes with the ability to make or communicate responsible decisions regarding health care, food, clothing, shelter or the effective management of his/her property and affairs.  That disability is diagnosed as: (name and/or describe) __________________ _______________________________________________________________ .  The nature of the disability is: (name and/or describe) ____________________ ________________________________________________________________ .  The cause of the disability is: (explain) _________________________________ ________________________________________________________________  The extent of the disability is: (explain) _________________________________ ________________________________________________________________  The probable duration of the disability is: (time and/or extent) ______________ ________________________________________________________________  The usual treatments for the disability are: (explain) ______________________ ________________________________________________________________ [ ] In my opinion, the patient has a disability that prevents him/her from making or communicating any responsible decisions concerning his/her person . [ ] In my opinion, the patient has a disability which prevents him/her from making or communicating some responsible decisions concerning his/her person . The patient is able to decide: (describe and explain) ______________________________________ ______________________________________________________________________ [ ] In my opinion, the patient has a disability which prevents him/her from making or communicating any responsible decisions concerning his/her property . [ ] In my opinion, the patient has a disability which prevents him/her from making or communicating some responsible decisions concerning his/her property . The patient is able to decide: (describe and explain) ______________________________________ ______________________________________________________________________ [ ] In my opinion, the patient does have sufficient mental capacity to understand and manage his/her own affairs. [ ] In my opinion, the patient does not have sufficient mental capacity to understand and manage his/her own affairs. [ ] does not have a physical or mental disability that interferes with the ability to make or communicate responsible decisions regarding health care, food, clothing, shelter or administration of property. The patient retains the ability to perform the following functions: (name and/or describe) _____________________________________________________________ ______________________________________________________________________ The patient [ ] does or [ ] does not require institutional care. I solemnly affirm under the penalties of perjury and upon personal knowledge that the contents of the foregoing certification are true. Witness my signature this the ___________________ (date) . ________________________________ (Printed Name of Physician) ________________________________ (Signature of Physician)