Fill and Sign the Physicians Affidavit Note This Affidavit Will Be Used in a Legal Form

SAMPLE PHYSICIAN’S AFFIDAVIT (Brain Injury) NOTE: This affidavit will be used in a legal proceeding to appoint a guardian for the patient named below. The information it contains must be based on your personal examination of the patient. Thank you for your concern and cooperation. IS THIS AN EMERGENCY GUARDIANSHIP PETITION? If an emergency appointment of guardian is needed, please complete page three (3) of this form in addition to pages 1 and 2. PAT IENT’S NAME: John Smith ADDR ESS: 10000 Delaware Avenue, Georgetown, DE 19947 DATE OF BIRTH: February 21, 2001 Dr. James Montgomery located at: Sussex Memorial Hospital, 10 Beech Nut Ave., Milford, DE (Physician’s name) (Address) (302)424 -4242 (Telephone number) I am duly licensed and accredited in the following areas o f medical practice: Delaware and Maryland Internal Medicine The history of my involvement with this patient is the following: Attending physician at the F acility Primary Care Physician /Provider Primary Doctor from since 2005 Pt. established care with our practice 2005 Diagnosis: (Severe) Anoxic Brain Injury – Traumatic Brain Injury - Encephalopathy I personally e xamined this patient on: January 21 , 20 19 . The examination lasted approximate ly __________ 30:00 minutes _ (Time) Relevant test s and results: Computerized tomography (CT). A CT (or "cat") Magnetic resonance imaging (MRI), Reviewed Labs, and Physical Examination, reviewed medical records , Mini Mental Exam (MMSE) Does the patient have difficulty communicating? If so, describe the difficulty in detail, and provide the cause of the patient’s difficulty with communication: Non -Verbal, does not follow or comprehend commands Based on tests and my examination of this patient, it is my professional opinion that she/he: does not have  does have a disability that significantly interferes with the ability to make r esponsible decisions regarding health care, food , clothing , shelter, or finances. (Optional) The following documents are attached as supporting information regarding the particulars of the disability : __________________________________________________________________________ If the patient has a cognitive disability, describe that disability: Severe Anoxic Br ain Injury, Non -Verbal Communication, Impaired cognition, convulsions, seizures , Severe Encephalopathy ____________________________________________ _____________________________ The cognitive disability impairs the patient’s ability to perform the following functions: Patient needs assistance with daily living activities (ADLs), including bathing, clothing, feeding, medications, financial decisions _____________________________________________ ______________________________ In my opinion, the patient does have  does not have sufficient mental capacity to understand the nature of guardianship in order to consent to the appointment of a guardian. I solemnly swear and affirm under the penalties of perjury and upon personal knowledge that the contents of this affidavit are true. _____________________________ ___________________________ Date Physician’s Signature ____________________________ Printed Name SWORN TO AND SUBSCRIBED before me this _______day of ___________ 20__. ____________________________ Notary Public SAMPLE PHYSICIAN’S AFFIDAVIT (Dementia) NOTE: This affidavit will be used in a legal proceeding to ap point a guardian for the patient named below. The information it contains must be based on your personal examination of the patient. Thank you for your concern and cooperation. IS THIS AN EMERGENCY GUARDIANSHIP PETITION? If an emergency appointment of guardian is needed, please complete page three (3) of this form in addition to pages 1 and 2. PAT IENT’S NAME: Luke Spencer ADDR ESS: 500 N. 100 th Street, Wilmington, DE 19801 DATE OF BIRTH: May 15, 1935 Dr. Roman Brady located at: 499 O ogleston Stanton Road, Newark, DE 19713 (Physician’s name) (Address) 302 -999 -9999 _ (Telephone number) I am duly licensed and accredited in the following areas of medical practice: Delaware and Texas - Internal Medicine – Family Medicine The history of my involvement with this patient is the following: I am attending physician – Primary Care Physician Diagnosis: Alzheimer - Dementia ( Note one of these: Mild, Moderate or Severe) I personally e xamined this patient o: January 21 , 20 19 . The examination lasted approximatel y ___________ 20:00 (two times) (Time) Relevant tests and results: Physical Examination, reviewed labs, C T Scan (Head) Mini Mental Exam - MMSE10/30(scored) (The maximum MMSE score is 30 points . A score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates severe dementia. On average, the MMSE score of a person with Alzheimer's declines about two to four points each year. ) Does the patient have difficulty communicating? If so, describe the difficulty in detail, and provide the cause of the patient’s difficulty with communication: Aphasia - Difficulty speaking, trouble understanding speech, difficulty with word recall and problems with reading or writing Patient suffers from preservations and expressive aphasia due to his Dementia Based on tests and my examination of this patient, it is my professional opinion that she/he: does not have  does have a disability that significantly interferes with the ability to make r esponsible decisions regarding health care, food, clothing, shelter, or finances. (Optional) The following documents are attached as supporting information regarding the particulars of the disability: Mini Mental Exam (MMSE) If the patient has a cognitive disability, describe that disability: Alzheimer’s Dementia Disease –Visual Varient – Severe End stages of Demen tia Patient has difficulty remembering who people are and he has hallucinations and delusions The cognitive disability impairs the patient’s ability to perform the following functions: Needs a id with activities of daily living, such as clothing, feeding, bathing , getting dressed, preparing meals, cannot handle own finances, unable to drive ______ _____________________________________________________________________ In my opinion, the patient does have  does not have sufficient mental capacity to understand the nature of guardianship in order to consent to the appointment of a guardian. I solemnly swear and affirm under the penalties of perjury and upon personal knowledge that the contents of this affidavit are true. _____________________________ ___________________________ Date Physician’s Signature ____________________________ Printed Name SWORN TO AND SUBSCRIBED before me this _______day of ___________ 20__. ____________________________ Notary Public SAMPLE PHYSICIAN’S AFFIDAVIT (Autism) NOTE: This affidavit will be used in a legal proceeding to appoint a guardian for the patient named below. The information it contains must be based on your personal examination of the patient. Thank you for your concern and cooperation. IS THIS AN EMERGENCY GUARDIANSHIP PETITION? If an emergency appointment of guardian is needed, please complete page three (3) of this form in addition to pages 1 and 2. PAT IENT’S NAME: Suzy Ann Jones ADDRESS: 88888 Berry Lane, Milford, DE 19963 DAT E OF BIRTH: 03/03/95 Dr. Chase Newman located at: 1000 My Little Pony Road, Milford, DE 19963 (Physician’s name) (Address) (302) 898 -9999 (Telephone number) I am duly licensed and accredited in the following areas of medical practice: Pediatric Internal Medicine Licensed in Delaware and Maryland The history of my involvement with this patient is the following: Primary Care Physician since 2000 Diagnosis: Autism Spectrum Disorder with Cognitive Developmental Delay Autism Spectrum Disorder (ASD) (Mild, Moderate or Severe) Global Delay / Spastic Quadriplegic Cerebral Palsy Patient has issues with communication, social, verbal, and motor skills. I personally examined this patient on 02/22/2019 The examination lasted approximatel y ___________ 30:00 minutes (Time) Relevant tests and results: MRI, CT Scan, Reviewed Labs, Does the patient have difficulty communicating? If so, describe the difficulty in detail, and provide the cause of the patient’s difficulty with communication: Speech Defect , Reasoning, J udgment , Minimal Speech , Speech is 1 -2 words Based on tests and my examination of this patient, it is my professional opinion that she/he: does not have  does have A disability that significantly interferes with the ability to make r esponsible decisions regarding health care, food, clothing, shelter, or finances. (Option al) The following documents are attached as supporting information regarding the particulars of the disability: IEP Records from Sussex Consortium If the patient has a cognitive disa bility, describe that disability: Severe Autism, Intellectual Aggressive Behavior, self -injury, Global Developmental Delay Severe Intellectual Disability, Non -Verbal, Intractable Seizure Disorder Angelman Syndrome __________________________________________________________________________ The cognitive disability impairs the patient’s ability to perform the following functions: unable to manage his medical condition, medications or finances. He needs assistance with daily living, bathing, feeding, and clothing . Patient require s maximum assistance wi th all ADL’s and total care ____________________________________________________ _______________________ In my opinion, the patient does have  does not have sufficient mental capacity to understand the nature of guardianship in order to consent to the appointment of a guardian. I solemnly swear and affirm under the penalties of perjury and upon personal knowledge that the contents of this affidavit are true. _____________________________ ___________________________ Date Physician’s Signature ____________________________ Printed Name SWORN TO AND SUBSCRIBED before me this _______day of ___________ 20__. ____________________________ Notary Public SAMPLE PHYSICIAN’S AFFIDAVIT (Schizo affective and Bi -Polar Disorder) NOTE: This affidavit will be used in a legal proceeding to appoint a guardian for the patient named below. The information it contains must be based on your personal examination of the patient. Thank you for your concern and cooperation. IS THIS AN EMERGENCY GUARDIANSHIP PETITION? If an emergency appointment of guardian is needed, please complete page three (3) of this form in addition to pages 1 and 2. PAT IENT’S NAME: Erika Boulevard ADD RESS: 10910 New England Street, Smyrna, DE 19977 DATE OF BIRTH: 10/10/90 Dr. Rick Bau er located at: St. James Facility, 1976 Liberty Lane, Dover, DE 19901 (Physician’s name) (Address) (302)743 -0002 (Telephone number) I am duly licensed and accredited in the following areas of medical practice: Psychiatry ____________________________________________________________________________ The history of my involvement with this patient is the following: Inpatient Psychiatrist ____________________________________________________________________________ ____________ ________________________________________________________________ ____________________________________________________________________________ Diagnosis: Schizoaffective Disorder, Bi -Polar Type, Depressed – Severe ] (Mild, Moderate, Severe) I personally e xa mined this patient on 11/06/2018 . The examination lasted approximatel y __________15 -20 minutes (Time) Relevant tests and results: EKG, Blood Test, Urine Analysis Patient is Psychiatric, Paranoid Refuses Medication Does the patient have difficulty communicating? If so, describe the difficulty in detail, and provide the cause of the patient’s difficulty with communication: Patient lacks reasoning Based on tests and my examination of this patient, it is my professional opinion that she/he: does not have  does have a disability that significantly interferes with the ability to make r esponsible decisions regarding health care, food, clothing, shelter, or finances. (Optional) The following documents are attached as supporting information regarding the particulars of the disability: __________________________________________________________ ________________ If the patient has a cognitive disability, describe that disability: Chronic Psychosis Auditing Hallucinations and Paranoia __________________________________________________________________________ __________________________________________________________________________ The cognitive disability impairs the patient’s ability to perform the following functions: Needs help with all ADL’s and Manage Medication In my opinion, the patient does have  does not have sufficient mental capacity to understand the nature of guardianship in order to consent to the appointment of a guardian. I solemnly swear and affirm under the penalties of perjury and upon personal knowledge that the contents of this affidavit are true. _____________________________ ___________________________ Date Physician’s Signature ____________________________ Printed Name SWORN TO AND SUBSCRIBED before me this _______day of ___________ 20__. ____________________________ Notary Public