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A ( @?!A Ff (  $$$###""""""""""""""""""""""""""""""""""""""""""""""""""""""""""""###%%%JJJ???>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>???KKKIIIIIILLLLLLOOOOOOTTTTTTWWWWWWYYYYYYZZZZZZZZZZZZ\\\\\\]]]d]Ud]U]]]]]]Ő]]]]]]Ő]]]___Ő___```Ő```bbb󐊄Őbbbbbb񐊄Őbbbcccd]Ud]Uccc;3';3';3';3';3'VTPccceeefffnllꃃooo~}}fsࡱ> JMI bjbjWW ;,55$ |D^^8$L,@jj4nnn;,=,=,=,=,=,=,$.1ta,R^RRa,^^rv,LLLR^^8;,LR;,LLr'T(`3F>^E(',,0,S("3D~"3((&"3)n"Lnnna,a,nnn,RRRR"3nnnnnnnnn $:  IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING In the Matter of ______________________, An Alleged Incapacitated Person. NO. MEDICAL REPORT OF PHYSICIAN OR PSYCHOLOGIST Name and Address of Evaluating Physician or Psychologist: (if Report of M.D. or D. O.): NAME: ADDRESS: CITY, STATE, ZIP CODE: 2. Information Regarding Physician or Psychologist: Medical Specialty (E.G. family practice, psychiatry): Please list any pertinent education and experience (attach curriculum vitae if desired): 3. Patient was last examined or evaluated on [date]: 4. Summary of the relevant medical, functional, neurological, psychological or psychiatric history and conditions of the alleged incapacitated person: List condition(s): 5. Current medications taken by the alleged incapacitated person and effect on ability to understand: 6. Prognosis for alleged incapacitated persons recovery: 7. Ability of __________________ to handle her own affairs: In my medical opinion, the ability of ___________________to handle her own affairs is as follows: In my opinion, _______________needs help in the following specific areas: 8. Ability of Alleged Incapacitated person to make her own medical decisions: ___________________ [ ] IS [ ] IS NOT able to make medical decisions on her own behalf for the following reasons: 9. Ability of _________________________ to participate in guardianship hearing: In my opinion ____________________ [ ] IS [ ] IS NOT able to participate in the guardianship hearing [with the following limitations, if any]: 10. Names of persons with whom physician has met or spoken regarding the alleged incapacitated person: [Specify names, addresses, and relationship to ___________________________ Dated: , 20_____. 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