Fillable Form 1: (Pinellas County Clerk of the Circuit Court and Comptroller)

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Form 1: (Pinellas County Clerk of the Circuit Court and Comptroller)

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The Form 1: (Pinellas County Clerk of the Circuit Court and Comptroller) form is 1 page long and contains:

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  • 0 check-boxes
  • 34 other fields

Country of origin: US
File type: PDF

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Ward Name: Case Number:
Annual Physician’s Report of Examination
(All items must be answered)
1
Diagnosis:
2
Recommended Treatment:
3
Prognosis:
4
The current level of capacity of the patient is:
5
In your opinion, is the patient capable of exercising the following?(Use checkboxes Below
Right to marry:
Right to vote:
Right to personally apply for government benefits:
Right to have a driver’s license:
Right to travel:
Right to seek or retain employment:
Right to contract:
Right to sue and be sued:
Right to manage property or to make any give of disposition:
Right to determine residence:
Right to consent to medical treatment:
Right to make decisions about social environment or social aspects:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
6
Date of Examination:
Doctor Signature
Doctor Address (Street Address, City, State, Zip)
Date of Doctor’s Signature
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Form 1: (Pinellas County Clerk of the Circuit Court and Comptroller)

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Completed 10 February 2021

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