Fillable Physicians Certificate of Medical Examination To the Physician (Denton County, Texas)

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Physicians Certificate of Medical Examination To the Physician (Denton County, Texas)

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Physician’s Certificate of Medical Examination Page 1 of 4
Physician’s Certificate of Medical Examination
Revision September 2015
In the Matter of the Guardianship of For Court Use Only
_____________________________________, Court Assigned:__________________
an Alleged Incapacitated Person
To the Physician
This form is to enable the Court to determine whether the individual identified above is incapacitated
according to the legal definition (on page 3), and whether that person should have a guardian appointed.
1. General Information
Physician’s Name __________________________________________ Phone: (______)_________________
Office Address __________________________________________________________________________
__________________________________________________________________________
YES NO I am a physician currently licensed to practice in the State of Texas.
Proposed Ward’s Name ______________________________________________________________________
Date of Birth _________________________________ Age___________ Gender M F
Proposed Ward’s Current Residence: __________________________________________________________
I last examined the Proposed Ward on _________________________________, 20______ at:
a Medical facility the Proposed Ward’s residence Other: __________________________
YES NO The Proposed Ward is under my continuing treatment.
YES NO Before the examination, I informed the Proposed Ward that communications with me would not
be privileged.
YES NO A mini-mental status exam was given. If “YES,” please attach a copy.
2. Evaluation of the Proposed Ward’s Physical Condition
Physical Diagnosis: ___________________________________________________________________________
a. Severity: Mild Moderate Severe
b. Prognosis: ___________________________________________________________________________
c. Treatment/Medical History: _________________________________________________________________
3. Evaluation of the Proposed Ward’s Mental Functioning
Mental Diagnosis: ___________________________________________________________________________
a. Severity: Mild Moderate Severe
b. Prognosis: ___________________________________________________________________________
c. Treatment/Medical History: _________________________________________________________________
If the mental diagnosis includes dementia, answer the following:
YES NO ---- It would be in the Proposed Ward’s best interest to be placed in a secured facility for the elderly
or a secured nursing facility that specializes in the care and treatment of people with dementia.
YES NO ---- It would be in the Proposed Ward’s best interest to be administered medications appropriate for
the care and treatment of dementia.
YES NO ---- The Proposed Ward currently has sufficient capacity to give informed consent to the
administration of dementia medications.
d. Possibility for Improvement:
YES NO ---- Is improvement in the Proposed Ward's physical condition and mental functioning possible?
If “YES,” after what period should the Proposed Ward be reevaluated to determine whether a guardianship
continues to be necessary? _______________________________________________
Physician’s Certificate of Medical Examination Page 2 of 4
4. Cognitive Deficits
a. The Proposed Ward is oriented to the following (check all that apply):
Person Time Place Situation
b. The Proposed Ward has a deficit in the following areas (check all areas in which Proposed Ward has a deficit):
--- Short-term memory
--- Long-term memory
--- Immediate recall
--- Understanding and communicating (verbally or otherwise)
--- Recognizing familiar objects and persons
--- Solve problems
--- Reasoning logically
--- Grasping abstract aspects of his or her situation
--- Interpreting idiomatic expressions or proverbs
--- Breaking down complex tasks down into simple steps and carrying them out
c. YES NO -- The Proposed Ward’s periods of impairment from the deficits indicated above (if any) vary
substantially in frequency, severity, or duration.
5. Ability to Make Responsible Decisions
Is the Proposed Ward able to initiate and make responsible decisions concerning himself or herself regarding the
following:
YES NO ---- Make complex business, managerial, and financial decisions
YES NO ---- Manage a personal bank account
If “YES,” should amount deposited in any such bank account be limited? YES NO
YES NO ---- Safely operate a motor vehicle
YES NO ---- Vote in a public election
YES NO ---- Make decisions regarding marriage
YES NO ---- Determine the Proposed Ward’s own residence
YES NO ---- Administer own medications on a daily basis
YES NO ---- Attend to basic activities of daily living (ADLs) (e.g., bathing, grooming, dressing, walking,
toileting) without supports and services
YES NO ---- Attend to basic activities of daily living (ADLs) (e.g., bathing, grooming, dressing, walking,
toileting) with supports and services
YES NO ---- Attend to instrumental activities of daily living (e.g., shopping, cooking, traveling, cleaning)
YES NO ---- Consent to medical and dental treatment at this point going forward
YES NO ---- Consent to psychological and psychiatric treatment at this point going forward
6. Developmental Disability
YES NO ---- Does the Proposed Ward have developmental disability?
If “NO,” skip to number 7 below.
If “YES,” answer the following question and look at the next page.
Is the disability a result of the following? (Check all that apply)
YES NO ---- Intellectual Disability ?
YES NO ---- Autism?
YES NO ---- Static Encephalopathy?
YES NO ---- Cerebral Palsy?
YES NO ---- Down Syndrome?
YES NO ---- Other? Please explain __________________________________________________
Answer the questions in the “Determination of Intellectual Disability” box below only if both of the following are true:
(1) The basis of a proposed ward’s alleged incapacity is intellectual disability.
and
Physician’s Certificate of Medical Examination Page 3 of 4
(2) You are making a “Determination of Intellectual Disability” in accordance with rules of the executive
commissioner of the Health and Human Services Commission governing examinations of that kind.
If you are not making such a determination, please skip to number 7 below.
“DETERMINATION OF INTELLECTUAL DISABILITY”
Among other requirements, a Determination of Intellectual Disability must be based on an interview with the Proposed
Ward and on a professional assessment that includes the following:
1) a measure of the Proposed Ward’s intellectual functioning;
2) a determination of the Proposed Ward’s adaptive behavior level; and
3) evidence of origination during the Proposed Ward’s developmental period.
As a physician, you may use a previous assessment, social history, or relevant record from a school district, another
physician, a psychologist, an authorized provider, a public agency, or a private agency if you determine that the previous
assessment, social history, or record is valid.
1. Check the appropriate statement below. If neither statement is true, skip to number 7 below.
I examined the proposed ward in accordance with rules of the executive commissioner of the Health and
Human Services Commission governing Intellectual Disability examinations, and my written findings and
recommendations include a determination of an intellectual disability.
I am updating or endorsing in writing a prior determination of an intellectual disability for the proposed ward
made in accordance with rules of the executive commissioner of the Health and Human Services Commission by
a physician or psychologist licensed in this state or an authorized provider certified by the Department of Aging
and Disability Services to perform the examination.
2. What is your assessment of the Proposed Ward’s level of intellectual functioning and adaptive behavior?
Mild (IQ of 50-55 to approx. 70) Moderate (IQ of 35-40 to 50-55)
Severe (IQ of 20-25 to 35-40) Profound (IQ below 20-25)
3. Yes No ---- Is there evidence that the intellectual disability originated during the Proposed Ward’s
developmental period?
Note to attorneys: If the above box is filled out because a determination of intellectual disability has been made in accordance
with rules of the executive commissioner of the Health and Human Services Commission governing examinations of that kind, a
Court may grant a guardianship application if (1) the examination is made not earlier than 24 months before the date of the
hearing or (2) a prior determination of an intellectual disability was updated or endorsed in writing not earlier than 24 months
before the hearing date. If a physician’s diagnosis of intellectual disability is not made in accordance with rules of the executive
commissioner — and the above box is not filled out — the court may grant a guardianship application only if the Physician’s
Certificate of Medical Examination is based on an examination the physician performed within 120 days of the date the
application for guardianship was filed. See Texas Estates Code § 1101.104(1).
7. Definition of Incapacity
For purposes of this certificate of medical examination, the following definition of incapacity applies:
An “Incapacitated Person” is an adult who, because of a physical or mental condition, is substantially unable to:
(a) provide food, clothing, or shelter for himself or herself; (b) care for the person’s own physical health; or
(c) manage the person’s own financial affairs. Texas Estates Code § 1002.017.
8. Evaluation of Capacity
YES NO ---- Based upon my last examination and observations of the Proposed Ward, it is my opinion that the
Proposed Ward is incapacitated according to the legal definition in section 1002.017 of the
Texas Estates Code, set out in the box above.
If you indicated that the Proposed Ward is incapacitated, indicate the level of incapacity:
Total ------------- The Proposed Ward is totally without capacity (1) to care for himself or herself and (2) to manage
his or her property.
Partial ----------- The Proposed Ward lacks the capacity to do some, but not all, of the tasks necessary to care for
himself or herself or to manage his or her property.
Physician’s Certificate of Medical Examination Page 4 of 4
Evaluation of Capacity (continued)
If you indicated the Proposed Ward’s incapacity is partial, what specific powers or duties of the guardian should be
limited if the Proposed Ward receives supports and services? ___________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
If you answered “NO” to all of the questions regarding decision-making in Section 5 (on page 2) and yet still believe
the Proposed Ward is partially incapacitated, please explain: ___________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
If you answered “YES” to any of the questions regarding decision-making in Section 5 (on page 2) and yet still
believe the Proposed Ward is totally incapacitated, please explain: _______________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
9. Ability to Attend Court Hearing
YES NO ---- The Proposed Ward would be able to attend, understand, and participate in the hearing.
YES NO ---- Because of the Proposed Ward’s incapacities, I recommend that the Proposed Ward not appear
at a Court hearing.
YES NO ---- Does any current medication taken by the Proposed Ward affect the demeanor of the Proposed
Ward or his or her ability to participate fully in a court proceeding?
10. What is the least restrictive placement that you consider is appropriate for the Proposed Ward:
------------ Nursing home level of care --- Assisted Living Facility
------------ Group Home --- Memory care unit
------------ Own Home or with family --- Other ________________________________________________
11. Additional Information of Benefit to the Court: If you have additional information concerning the Proposed
Ward that you believe the Court should be aware of or other concerns about the Proposed Ward that are not
included above, please explain on an additional page.
________________________________________ ________________________________
Physician’s Signature Date
________________________________________ ________________________________
Physician’s Name Printed License Number
Revised September 2015
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Physicians Certificate of Medical Examination To the Physician (Denton County, Texas)

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Completed 13 February 2021

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