STATE OF SOUTH CAROLINA	)
)	IN THE PROBATE COURT
COUNTY OF:	)
)	EXAMINER’S REPORT
IN THE MATTER OF:	)
)	CASE NUMBER:

Please answer the following questions concerning the above person. Please provide details at the end of this form or an attached sheet of paper.

1.	Have you treated this person before	Yes	No

If yes, give brief history.

Has this person ever been rated or found:

disabled	Yes	No	Unknown

mentally ill or incompetent	Yes	No	Unknown

chemically dependent	Yes	No	Unknown

Can the above person:

care for self (personal hygiene)	Yes	No	Unknown

prepare meals and/or clean house	Yes	No	Unknown

maintain bank accounts or funds	Yes	No	Unknown

pay bills	Yes	No	Unknown

live independently	Yes	No	Unknown

operate a car	Yes	No	Unknown

take medications unsupervised	Yes	No	Unknown

Would the above person benefit from:

further education	Yes	No	Unknown

further training	Yes	No	Unknown

therapy of some sort	Yes	No	Unknown

medical aids or equipment	Yes	No	Unknown

an operation or medical procedure(s)	Yes	No	Unknown

structured living arrangements	Yes	No	Unknown

Has the above person had in the last six months:

hospitalization(s)	Yes	No	Unknown

therapy or treatment	Yes	No	Unknown

inpatient or outpatient surgery	Yes	No	Unknown

major medical test(s)	Yes	No	Unknown

psychological or psychiatric testing	Yes	No	Unknown

6.	In your opinion, does this person have the mental or physical capacity to effectively manage his/her property and

financial affairs	Yes	No

and /or make necessary daily living and health care decisions	Yes	No

To your knowledge does this person have:

a power of attorney	Yes	No	Unknown

a health care power of attorney or	Yes	No	Unknown

a “living will”	Yes	No	Unknown

Does the above person have any of the following coverages?

health insurance	Yes	No	Unknown

medicare	Yes	No	Unknown

medicaid	Yes	No	Unknown

veteran’s health care	Yes	No	Unknown

9.	Does this person have a primary caretaker?	Yes	No	Unknown

If yes, please give available information on name, address, and relationship to above person.

SWORN to before me this

day of

Date:

, 20

Examiner’s Signature

Notary Public for South Carolina
Examiner’s Name

My Commission Expires:

Use this space for explanations or additional comments.

FORM #538PC (2/2004)	Page 2 of 2

FORM #538PC (2/2004)	Page 1 of 2

62 5-303, 62-5-407

STATE OF SOUTH CAROLINA

EOsborne

2004-02-10

HMcCaw

S.C. Judicial Dept.