STATE OF WISCONSIN, CIRCUIT COURT, COUNTY
For Official Use
IN THE MATTER OF


Amended
Examining Physician's or Psychologist's Report

Date of Birth
Case No.
TO THE COURT:
I am a physician. psychologist.
This report is made to the court as required when it is proposed to appoint a guardian for an individual on the ground that the individual allegedly has incompetency. This report contains my professional opinion regarding the presence and likely duration of any medical or other condition causing the proposed ward to have incapacity.
I certify that I have, by personal examination and inquiry, satisfied myself as to the condition of competency of this individual and the result of my evaluation and inquiry will be found in my answers to the following questions, which answers are true to the best of my knowledge. All opinions are provided to a reasonable degree of professional certainty. Questions requiring an opinion for which I cannot provide an answer to a reasonable degree of professional certainty are left blank.

Signature of Examiner

Name printed or typed

Address

Date
NOTICE OF RIGHTS
Prior to examination of this individual for whom guardianship is proposed on the ground that the individual allegedly has incompetency, was the individual informed that:
1. Statements made by the individual may be used as a basis for a finding of incompetency ........ Yes No
2. The individual has a right to refuse to participate in the examination, absent a court order, or speak to you
Yes No
3. You are required to report to the court even if the individual does not speak to you ................... Yes No

PERSONAL AND FAMILY HISTORY
Date of Birth: Age: Sex: Female Male
Marital Status:
Children:
Occupation and Employment:
Veteran: Yes No

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