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Guardianship Evaluation Template
Source of Referral:
Referral Issue:
Sources of Information:
Examiners Name:
Qualifications of Examiner:
Statement of Non-confidentiality:
Past Personal History:
Current Lifestyle:
Past Psychiatric History:
Past Medical History:
C. Current. Medications
Family History:
Sexual and Marital History:
Educational History:
Employment History:
Guardianship Evaluation Template
Drug/Alcohol History:
Legal History:
Mental Status Evaluation:
Brief Summary of Relevant Documents:
Psychiatric Diagnosis (five axes):
Opinion: It is my opinion with reasonable medical certainty that…
A. Guardianship/Conservatorship (G/C) is needed because: C. Alternatives to G/C are/are not available. Treatment and Rehabilitation could be expected to: E. Respondent may/may not attend hearing without risk of physical harm to himself. RESPONDENT NAME: JOHN DOE
ENTRAL STATE HOSPITAL.
RESPONDENT NUMBER:
DATE: January 1, 2009
RESPONDENT: JOHN DOE
RESPONDENT'S SOCIAL SECURITY NUMBER:
SOURCE OF REFERRAL: Lisa Campbell, M. S.S.W ., Staff Social W o rker,
Cen tra l
State Hospital, Geriatric Service.
REFERRAL ISSUE: Disability Determination
SOURCES OF INFORMATION:
Admission History and Psychiatric Evaluation by Dr. Charles Francke, 1/8/99. Neurological Consultation by Dr. Victor Matibag, 1/28/99 and 3/4/99. Physical Therapy Evaluations by Steven Powell, P.T., 1/23/99 and 3/8/99. Occupational Therapy Progress Note by Brian ladarola, O.T.R., 3/11/99. Laboratory Reports from Central State Hospital including thyroid function tests, TSH, comprehensive metabolic profile, and complete blood count, chest x-rays p erformed 2/11 /99 and 1 /21/99, cerv ical spine x-ray performed 2 /11/99. N e u r o l o g i c a l C o n s u l t a t i o n p e r f o r m e d a t U n i v e r s i t y o f L o u i s v i l l e Comprehensive Treatment Plan Review performed at Central State Hospital, 8. An interview with John Doe conducted on the Geriatric Service at Central State Hospital, 4/13/99. Progress Notes of Charles Francke, M.D., 1/20/99, 1/25/99, 1/27/99, 1/29/99, 2/3/99, 2/8/99, 2/10/99, 2/12/99, 2/17/99, 2/18/99, 2/25/99, 3/3/99, 3 /5 /9 9 , 3 / 1 0 / 9 9 , 3 / 1 7 / 9 9 , 3 / 1 9 / 9 9 , 3 / 2 0 / 9 9 , 3 / 2 5 / 9 9 . 10. Discharge Summary from the 5-East Service of University of Louisville Hospital covering the p eriod 12/28 /98 through 1 /8/99. 11. Psychosocial Assessment by Lisa Campbell, M.S.S.W., 1/12/99. Dr. Meyer is a Board Certified General, Addiction and Forensic Psychiatrist. STATEMENT OF NONCONFIDENTIALITY: Mr. Doe was apprized of the non-confidentiality of the data obtained for this report. He did not appear to understand. G U A R D I A N S H I P E V A L U A T I O N
PAST PERSONAL HISTORY: Mr. Doe indicated that he grew up in
Breckinridge County, Kentucky, and completed the eighth grade, after which he quit school.
He was married at one time but does not recall the date and was divorced in 1990. He has four
children, one son and three daughters. Records reflect that his father was a farmer and alcoholic and
his mother a homemaker with no evidence from the records of any abuse in his childhood. He has
never had military service. He was employed for approximately 22 years of his life, 11 for
LG&E and 11 at "Doe Valley." Information from a daughter indicates she feels her father is
an alcoholic and has consumed alcohol heavily all of his life, with his last drink being
consumed on 10/12/98. He was admitted to the 5 East Service of the University of
Louisville Hospital on 12/28/98. He had been brought by his family to University of Louisville
Hospital Emergency Room for agitation since "a stroke in July of 1 998," for which he never
consulted a physician. The family believed that Mr. Doe was recently more easily
agitated, much more forgetful and frustrated. His last use of alcohol was determined by his
being arrested by the police for driving without a driver's license. His mental status examination
from the time of admission to University of Louisville Hospital which reflected that he was alert and
oriented but, later, there was evidence of deterioration and he was discharged from that facility with a
diagnosis of dementia with delusions. On 1/8/99, he was transferred to the Gero-psychiatry
Service at Central State Hospital for further evaluation and consideration of nursing home
placement. During his stay on the Gero-psychiatry Service, the records reflect that he has been
confused, disoriented, and noncompliant with medications. Examiners report repeatedly that
responses to most requests or questions are either "Nope" or "No." Management with current
psychotropic medications has resulted in, by the records, less hostility and argumentativeness and,
although medications to improve cognitive function have been employed, the records reflect there has
been no significant change
in memory or orientation. Mr. DOE'S family had obtained initially a Durable Power of Attorney and subsequently an Emergency Guardianship with permanent Guardianship proceedings pending. CURRENT LIFESTYLE: Mr. ' as been residing on the Gero-psychiatry Service at Central
State Hospital since 1/8/99 to the present time. He spends his days on the Unit, is somewhat
noncompliant with medications and requests for testing, but over time will generally comply with
reluctance. Records indicate he walks around the Unit with a stooped posture and is most non-
communicative and has repeatedly asserted that when released he will "drink whisky."
RESPONDENT NAME: JOHN DOE
ENTRAL STATE HOSPITAL.
RESPONDENT NUMBER:
PAST PSYCHIATRIC HISTORY:
5-East Service of the University of Louisville Hospital, 12/28/98 through 1/8/99 Gero-psychiatry Service of Central State Hospital, 1/8/99 to the present. PAST MEDICAL HISTORY:
Milk of Magnesia 30 cc b.i.d. PRN constipation. Cogentin 1 mg q 4 hrs PRN extra pyramidal side effects. P A G E 3 GUARDIANSHIP
EVALUATION
RESPONDENT NUMBER
FAMILY HISTORY: Records indicate that Mr. Doe’s father was a farmer and an alcoholic and his
mother a housewife. He grew up in rural Kentucky, leaving school in the eighth grade. He
has four children, one son and four daughters. He has been divorced since
1990. No information in reference to family psychiatric or medical
history is available.
SEXUAL AND MARITAL HISTORY: Mr. Doe was married at an unknown age and he
was divorced in 1990.
EDUCATIONAL HISTORY: Mr. Doe attended school in Breckinridge County,
Kentucky, as far as the eighth grade, quitting school at that point.
EMPLOYMENT HISTORY: Mr. Doe indicates that he was employed for LG&E for
eleven years and at "Doe Valley" for eleven years. He has been unemployed for ten years or more. Mr.
Doe receives Social Security in the amount of $751 per month
and is his own payee.
DRUG/ALCOHOL HISTORY: Records and family information indicate that Mr. Doe has consumed alcohol "alcoholically" all of his life in binges. His last binge terminated on October 12, 1998. LEGAL HISTORY:
B. Adult Record: Records reflect criminal justice issues in reference to alcohol use including DUI's, revocation of a driver's license and being arrested for driving with no driver's license. G E N E R A L A P P E A R A N C E : M r . D o e i s d i s h e v e l e d a n d u n k e m p t i n a p p e a r a n c e , shuffles in gait, and walks with a very stooped posture with his chin nearly touching his chest. His hair is unkempt and he is partially unshaven. He is somewhat resistive to examination and left his chair several times to leave the room. He makes no eye contact. There was no unusual odor. SENSORIUM: Mr. Doe is alert. He is oriented as to the city of Louisville only, with no knowledge of the precise place, date or surroundings. MEMORY: Remote memory as to his family and social history is markedly impaired. Recent memory: Objects after five minutes, 0/3. Immediate memory: not testable. GUARDIANSHIP EVALUATION
RESPONDENT NAME: JOHN DOE
CENTRAL STATE HOSPITAL
RESPONDENT NUMBER.
SPEECH: Slurred with decreased volume and an irregular cadence. INTELLIGENCE: There are marked impairments of the tests of intellectual functioning. He had no knowledge of American Geography and he has no testable fund of knowledge. PROVERB INTERPRETATION: Not testable. THOUGHT PROCESSES: Somewhat tangential with loosening of associations. PERCEPTIONS: Negative auditory hallucinations, negative visual hallucinations. THOUGHT CONTENT: Negative suicidal ideations, negative homicidal ideations, negative paranoid ideations, positive delusional thinking, and negative magical thinking. VEGETATIVE SIGNS OF DEPRESSION: Decreased energy, interest, and concentration with psychomotor retardation. BRIEF SUMMARY OF RELEVANT DOCUMENTS: Review of the records from the 5-East
Service of University of Louisville Hospital, including a Neurological Examination obtained at
that facility, reflects a long history of alcoholism with the possibility of a cerebral vascular accident in
mid-1 998, but no objective evidence for that diagnosis. Records clearly reflect dementia with marked
cognitive impairments and marked memory impairment with very little response to medications.
Laboratory investigations performed by both 5-East Service at University of Louisville Hospital and Central
State Hospital reflect only evidence of a cerebral vascular disease with negative MRI. Three separate
evaluations by neurologists indicate that there was no ongoing correctable neurological lesion
present. Psychosocial Evaluation performed at Central State Hospital reflects progressive
deterioration of his function throughout his life, especially within 1998, with deteriorating memory,
increasing confusion and disorientation. Progress Notes of Dr. Charles Francke at Central State
Hospital Gero-psychiatry Services reflect noncompliance, especially initially, with medications and
no change in cognitive function over a space of approximately two months. There have been
numerous documentations of Mr. Doe’s intention to resume drinking with a strong
suggestion that alcoholism is a source of his current dementia.
PSYCHIATRIC DIAGNOSES:
AXIS I: Alcohol-induced persisting dementia, with delusions. Alcohol dependence, early full remission, in a controlled environment. ' GUARDIANSHIP EVALUATION
RESPONDENT NUMBE.
"Entrapment neuropathy" Malnutrition. AXIS IV: Four - severe (joblessness, unemployability, severe medical problems). AXIS V: Current Global Assessment of Functioning: 20. Global Assessment of Functioning in the past year: 25. OPINION: It is my opinion, with reasonable medical certainty, that Mr. Doe requires the
appointment of a Permanent Guardian to oversee all of his affairs. The facts which support this
opinion include:
Mr. Doe’s level of cognitive functioning is impaired to such an extent that he is unable to make reasonable decisions concerning his personal, financial, and medical affairs. Family members are available to assume this role. Mr. Doe’s level of functioning and impairment in insight and judgment are sufficiently severe that he is unable to sustain himself in independent living with the supportive services of a nursing home required to sustain life. The nature and degree of cognitive impairments arising from severe neurological deterioration are such in nature that no appropriate treatment which will result in rehabilitation or reversal of the current processes is available. There are no facts available to this examiner which would not support the above opinion. Mr. Doe may appear in a hearing in reference to his disability determination without risk of physical harm to himself. GUARDIANSHIP EVALUATION

Source: ftp://adsl-068-016-190-059.sip.sdf.bellsouth.net/docs/Guardianship/Template.pdf

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