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Here is the text we could read:

 

I am a    [  ] Physician    [  ] Psychiatrist    [  ] Other _____________________ licensed to practice in the 
state of _________________. My License number is _______________ 

eport on Clinical Evaluation of ___________________________________ (patient’s 

name) 

To the evaluator: This document may be filed in a court case to appoint a guardian for the patient, and it 
may be treated as evidence of the patient’s incapacity. You may not be able to answer every question 
within the scope of your evaluation. Answer the questions for which you have information based on your 
personal observations, based on statements by the patient, or based on a source on which you 
commonly rely in your professional capacity. 

Sources of information 

I     [  ] am     [  ] am not      aware of the patient’s advance healthcare directive. 

My answers are based on the following sources of information. 

[  ]  My examination of the patient on __________________ (date) for the purpose 
of assessing capacity. On that date I spent about _______ minutes with the 
patient.  

[  ]  My general knowledge of the patient, who has been my patient since 
________________________ (date) and who I last saw on 
________________________ (date). On that date I spent approximately _______ 
minutes with the patient.  

[  ]  Review of the patient’s records. 

[  ]  Discussions with the patient. 

[  ]  Discussions with healthcare professionals involved in the patient’s care. 

[  ]  Discussions with the patient’s family, friends or caregivers. 

2. 

Overall condition 

The patient’s overall physical health is: 

Report on Clinical Evaluation 

Approved Board of District Court Judges September 12, 2012 
Revised December 18, 2019 

Page 1 of 5 

 
Evaluator’s Name 

ddress 

ity, State, Zip 

hone 

mail 

  A

  C

  P

  E

  R

. 

  1

 

. 

Daily functions (If you check moderate or 

Level of Impairment 

severe or if you have concerns, explain in the 
comments.) 
Activities of daily living (ADLs: bathing, grooming, 
dressing, mobility, toileting, eating, taking medication, 
etc) 
Instrumental Activities of Daily Living (IADLs: 
medication acquisition and monitoring, food shopping 
and preparation, transportation, paying bills, protect 
assets, resist fraud, etc.) 
Medical decision making (reason about health, express 
a choice, and understand, information, etc.) 
Care of home and functioning in community (manage 
home, health, telephone, mail, drive, leisure, etc.) 
Ability to protect self from harm, including physical 
harm, self-neglect, and financial exploitation. 

Comments 

None  Mild  Moderate  Severe 

Evaluated 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

[  ] 

Not 

[  ] 

[  ] 

[  ] 

[  ] 

. 

Behavior (If you check moderate or severe 

or if you have concerns, explain in the comments.) 
Rambling, nonsensical, or incoherent thinking 

None  Mild  Moderate  Severe 
[  ] 

[  ] 

[  ] 

[  ] 

Not 
Evaluated 
[  ] 

Level of Impairment 

Report on Clinical Evaluation 

Approved Board of District Court Judges September 12, 2012 
Revised December 18, 2019 

Page 2 of 5 

          3

          4

 

[  ]  Excellent 

[  ]  Good 

[  ]  Fair 

[  ]  Poor 

The patient’s overall physical health will: 

[  ]  Improve 

[  ]  Be stable 

[  ]  Decline 

[  ]  Uncertain 

The patient’s overall mental health is: 

[  ]  Excellent 

[  ]  Good 

[  ]  Fair 

[  ]  Poor 

The patient’s overall mental health will: 

[  ]  Improve 

[  ]  Be stable 

[  ]  Decline 

[  ]  Uncertain 

List your diagnoses that affect the patient’s functioning. 

Behavior (If you check moderate or severe 

4. 
or if you have concerns, explain in the comments.) 
Confabulation (fills in memory gaps with honestly 
believed false information) 

Seeing, hearing, smelling things not there 
Extreme suspiciousness; believing things that are not 
true against reason or evidence 

Uncontrollable worry, fear, thoughts 

Acting without considering consequences 

Acting with hostility, anger or violence 
Disinhibition, sexual aggression, uncontrollable 
behavior, 

Refuses to accept help or follow directions 

Wandering 

Comments (Attach additional pages if necessary.) 

Level of Impairment 

None  Mild  Moderate  Severe 

Not 
Evaluated 

[  ] 

[  ] 

[  ] 

[  ] 
[  ] 
[  ] 

[  ] 

[  ] 
[  ] 

[  ] 

[  ] 

[  ] 

[  ] 
[  ] 
[  ] 

[  ] 

[  ] 
[  ] 

[  ] 

[  ] 

[  ] 

[  ] 
[  ] 
[  ] 

[  ] 

[  ] 
[  ] 

[  ] 

[  ] 

[  ] 

[  ] 
[  ] 
[  ] 

[  ] 

[  ] 
[  ] 

[  ] 

[  ] 

[  ] 

[  ] 
[  ] 
[  ] 

[  ] 

[  ] 
[  ] 

. 

Cognitive and emotional impairment 

Level of Impairment 

(If you check moderate or severe or if you have 
concerns, explain in the comments.) 
Alertness/consciousness 
Memory and cognitive functioning 
Emotional and psychiatric functioning 

None  Mild  Moderate  Severe 
[  ] 
[  ] 
[  ] 

[  ] 
[  ] 
[  ] 

[  ] 
[  ] 
[  ] 

[  ] 
[  ] 
[  ] 

Not 

Evaluated 
[  ] 
[  ] 
[  ] 

In what areas are the patient’s decision making or thinking impaired and to what extent? 

. 

Risk of harm 

How likely is the risk that the patient may harm self or others? 

[  ]  Unlikely 

[  ]  Possible 

[  ]  Probable 

[  ]  Almost Certain 

Describe any significant risks the patient faces and note whether these risks are due to 
the patient’s condition and/or due to another person harming or exploiting the patient. 

Report on Clinical Evaluation 

Approved Board of District Court Judges September 12, 2012 
Revised December 18, 2019 

Page 3 of 5 

          5

        6

   

 

escribe any social factors (persons, supports, environment) that increase or decrease the 

risk. 

.  

Level of supervision needed 

In your opinion, what level of supervision does the patient need? 

[  ] No supervision 

[  ] Some supervision 

[  ] 24-hr supervision 

[  ] Locked facility 

8.  

Treatment and accommodation 

Describe treatments or accommodations that might enhance the patient’s functioning 
and any that have been tried but are ineffective. 

his report is complete and accurate to the best of my information and belief. If directed to do so, I am 

prepared to present to the court, by affidavit or testimony, my qualifications and my evidence. 

 
Date 

Signature ► 

Printed Name 

 

 

Report on Clinical Evaluation 

Approved Board of District Court Judges September 12, 2012 
Revised December 18, 2019 

Page 4 of 5 

      D

        7

              T

 

 

I certify that I filed with the court and am serving a copy of this Report on Clinical Evaluation on the 
following people. 

Certificate of Service 

Person’s Name 

Service Method 

Service Address 

Service 
Date 

(Petitioner or Attorney) 

(Respondent or 
Attorney) 

 

 

 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email 
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

[  ]  Mail 
[  ]  Hand Delivery 
[  ]  E-filed 
[  ]  Email  
[  ]  Left at business (With person in charge 

or in receptacle for deliveries.) 

[  ]  Left at home (With person of suitable 

age and discretion residing there.) 

Signature ► 

Printed Name 

 

 

 

 

 

 

 

 

 
Date 

 

Report on Clinical Evaluation 

Approved Board of District Court Judges September 12, 2012 
Revised December 18, 2019 

Page 5 of 5

Report on Clinical Evaluation

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 5
Fields(s): 189
Average fields per page: 37
Reading Level: Grade 13
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

evaluator_name was evaluator_s_name (0.56 conf)
users1_address_line_one was address (1.00 conf)
city_state_zip was city__state__zip (0.35 conf)
users1_phone_number was phone (1.00 conf)
email was email (0.38 conf)
licensed_practice was licensed_to_practice_in_the (0.44 conf)
license_number was my_license_number_is (0.44 conf)
page_field__1 was page_0_field_7 (0.31 conf)
page_field__2 was page_0_field_8 (0.31 conf)
page_field__3 was page_0_field_9 (0.31 conf)
state was state_of (0.46 conf)
patient__1 was patient_s (0.44 conf)
page_field__4 was page_0_field_12 (0.31 conf)
page_field__5 was page_0_field_13 (0.31 conf)
page_field__6 was page_0_field_14 (0.31 conf)
page_field__7 was page_0_field_15 (0.31 conf)
report_clinical_evaluation was report_on_clinical_evaluation_of (0.29 conf)
minutes was minutes_with_the (0.35 conf)
based_following_information was my_answers_are_based_on_the_following_sources_of_information (0.28 conf)
assessing_date_spent was of_assessing_capacity__on_that_date_i_spent_about (0.41 conf)
page_field__8 was page_0_field_20 (0.31 conf)
page_field__9 was page_0_field_21 (0.31 conf)
date_spent_approximately was date_on_that_date_i_spent_approximately (0.41 conf)
minutes_patient was minutes_with_the_patient (0.33 conf)
patient__2 was patient (0.38 conf)
general_patient_since was my_general_knowledge_of_the_patient__who_has_been_my_patient_since (0.37 conf)
page_field__10 was page_0_field_26 (0.31 conf)
page_field__11 was page_0_field_27 (0.31 conf)
page_field__12 was page_0_field_28 (0.31 conf)
page_field__13 was page_0_field_29 (0.31 conf)
page_field__14 was page_0_field_30 (0.31 conf)
page__1 was page_1_of_5 (0.42 conf)
page_check__1 was page_0_check_0 (0.34 conf)
page_check__2 was page_0_check_1 (0.33 conf)
physician_psychiatrist was i_am_a_physician_psychiatrist_other (0.33 conf)
sources_information was sources_of_information (0.39 conf)
page_check__3 was page_0_check_4 (0.33 conf)
examination_patient was my_examination_of_the_patient_on (0.42 conf)
page_check__4 was page_0_check_6 (0.33 conf)
review_patient_records was review_of_the_patient_s_records (0.32 conf)
discussions_patient was discussions_with_the_patient (0.39 conf)
discussions_involved_care was discussions_with_healthcare_professionals_involved_in_the_patient_s_care (0.32 conf)
family_friends_caregivers was discussions_with_the_patient_s_family__friends_or_caregivers (0.45 conf)
affect_patient_functioning was list_your_diagnoses_that_affect_the_patient_s_functioning (0.35 conf)
page__2 was page_2_of_5 (0.42 conf)
excellent was excellent (0.32 conf)
improve was improve (0.30 conf)
page_check__5 was page_1_check_2 (0.26 conf)
page_check__6 was page_1_check_3 (0.26 conf)
good was good (0.45 conf)
fair was fair (0.32 conf)
poor was poor (0.41 conf)
stable was be_stable (0.35 conf)
decline was decline (0.30 conf)
uncertain was uncertain (0.38 conf)
page_check__7 was page_1_check_10 (0.26 conf)
page_check__8 was page_1_check_11 (0.26 conf)
page_check__9 was page_1_check_12 (0.26 conf)
page_check__10 was page_1_check_13 (0.26 conf)
page_check__11 was page_1_check_14 (0.26 conf)
page_check__12 was page_1_check_15 (0.26 conf)
af_f was AFF061 (0.51 conf)
page_check__13 was page_1_check_17 (0.26 conf)
page_check__14 was page_1_check_18 (0.26 conf)
page_check__15 was page_1_check_19 (0.26 conf)
page_check__16 was page_1_check_20 (0.26 conf)
page_check__17 was page_1_check_21 (0.26 conf)
page_check__18 was page_1_check_22 (0.26 conf)
page_check__19 was page_1_check_23 (0.26 conf)
page_check__20 was page_1_check_24 (0.26 conf)
page_check__21 was page_1_check_25 (0.26 conf)
page_check__22 was page_1_check_26 (0.26 conf)
page_check__23 was page_1_check_27 (0.26 conf)
page_check__24 was page_1_check_28 (0.26 conf)
page_check__25 was page_1_check_29 (0.26 conf)
page_check__26 was page_1_check_30 (0.26 conf)
page_check__27 was page_1_check_31 (0.26 conf)
page_check__28 was page_1_check_32 (0.26 conf)
page_check__29 was page_1_check_33 (0.26 conf)
page_check__30 was page_1_check_34 (0.26 conf)
page_check__31 was page_1_check_35 (0.26 conf)
page_check__32 was page_1_check_36 (0.26 conf)
page_check__33 was page_1_check_37 (0.29 conf)
page_check__34 was page_1_check_38 (0.29 conf)
page_check__35 was page_1_check_39 (0.29 conf)
page_check__36 was page_1_check_40 (0.26 conf)
page_check__37 was page_1_check_41 (0.29 conf)
page_check__38 was page_1_check_42 (0.29 conf)
page_check__39 was page_1_check_43 (0.29 conf)
page_check__40 was page_1_check_44 (0.29 conf)
page_check__41 was page_1_check_45 (0.26 conf)
page__3 was page_3_of_5 (0.42 conf)
page_check__42 was page_2_check_0 (0.33 conf)
page_check__43 was page_2_check_1 (0.26 conf)
page_check__44 was page_2_check_2 (0.26 conf)
page_check__45 was page_2_check_3 (0.26 conf)
page_check__46 was page_2_check_4 (0.26 conf)
page_check__47 was page_2_check_5 (0.26 conf)
page_check__48 was page_2_check_6 (0.26 conf)
page_check__49 was page_2_check_7 (0.26 conf)
page_check__50 was page_2_check_8 (0.26 conf)
page_check__51 was page_2_check_9 (0.26 conf)
page_check__52 was page_2_check_10 (0.26 conf)
page_check__53 was page_2_check_11 (0.26 conf)
page_check__54 was page_2_check_12 (0.26 conf)
page_check__55 was page_2_check_13 (0.26 conf)
page_check__56 was page_2_check_14 (0.26 conf)
page_check__57 was page_2_check_15 (0.26 conf)
page_check__58 was page_2_check_16 (0.26 conf)
page_check__59 was page_2_check_17 (0.26 conf)
page_check__60 was page_2_check_18 (0.26 conf)
page_check__61 was page_2_check_19 (0.26 conf)
page_check__62 was page_2_check_20 (0.26 conf)
page_check__63 was page_2_check_21 (0.26 conf)
page_check__64 was page_2_check_22 (0.26 conf)
page_check__65 was page_2_check_23 (0.26 conf)
page_check__66 was page_2_check_24 (0.26 conf)
page_check__67 was page_2_check_25 (0.26 conf)
page_check__68 was page_2_check_26 (0.26 conf)
page_check__69 was page_2_check_27 (0.26 conf)
page_check__70 was page_2_check_28 (0.26 conf)
page_check__71 was page_2_check_29 (0.26 conf)
page_check__72 was page_2_check_30 (0.26 conf)
page_check__73 was page_2_check_31 (0.26 conf)
page_check__74 was page_2_check_32 (0.26 conf)
page_check__75 was page_2_check_33 (0.26 conf)
page_check__76 was page_2_check_34 (0.26 conf)
page_check__77 was page_2_check_35 (0.26 conf)
page_check__78 was page_2_check_36 (0.26 conf)
page_check__79 was page_2_check_37 (0.29 conf)
page_check__80 was page_2_check_38 (0.29 conf)
page_check__81 was page_2_check_39 (0.29 conf)
page_check__82 was page_2_check_40 (0.26 conf)
page_check__83 was page_2_check_41 (0.29 conf)
page_check__84 was page_2_check_42 (0.29 conf)
page_check__85 was page_2_check_43 (0.29 conf)
page_check__86 was page_2_check_44 (0.29 conf)
page_check__87 was page_2_check_45 (0.26 conf)
page_check__88 was page_2_check_46 (0.29 conf)
page_check__89 was page_2_check_47 (0.29 conf)
page_check__90 was page_2_check_48 (0.29 conf)
page_check__91 was page_2_check_49 (0.29 conf)
page_check__92 was page_2_check_50 (0.26 conf)
page_check__93 was page_2_check_51 (0.29 conf)
page_check__94 was page_2_check_52 (0.29 conf)
page_check__95 was page_2_check_53 (0.29 conf)
page_check__96 was page_2_check_54 (0.29 conf)
page_check__97 was page_2_check_55 (0.29 conf)
page_check__98 was page_2_check_56 (0.29 conf)
page_check__99 was page_2_check_57 (0.29 conf)
page_check__100 was page_2_check_58 (0.29 conf)
page_check__101 was page_2_check_59 (0.29 conf)
unlikely was unlikely (0.43 conf)
possible was possible (0.36 conf)
probable was probable (0.47 conf)
almost_certain was almost_certain (0.36 conf)
factors_increase_decrease was describe_any_social_factors__persons__supports__environment__that_increase_or_decrease_the (0.35 conf)
risk was risk (0.41 conf)
tried_ineffective was and_any_that_have_been_tried_but_are_ineffective (0.44 conf)
users1_signature was signature (1.00 conf)
signature_date was date (1.00 conf)
page_field__15 was page_3_field_5 (0.36 conf)
page__4 was page_4_of_5 (0.42 conf)
supervision__1 was no_supervision (0.39 conf)
supervision__2 was some_supervision (0.39 conf)
hr_supervision was 24_hr_supervision (0.31 conf)
locked_facility was locked_facility (0.39 conf)
page_field__16 was page_4_field_0 (0.31 conf)
page_field__17 was page_4_field_1 (0.36 conf)
page_field__18 was page_4_field_2 (0.36 conf)
page__5 was page_5_of_5 (0.42 conf)
left_home_person_suitable was left_at_home__with_person_of_suitable (0.45 conf)
mail was mail (0.38 conf)
hand_delivery was hand_delivery (0.35 conf)
e_filed was e_filed (0.48 conf)
page_check__102 was page_4_check_4 (0.26 conf)
left_business_person_charge was left_at_business__with_person_in_charge (0.48 conf)
page_check__103 was page_4_check_6 (0.26 conf)
page_check__104 was page_4_check_7 (0.26 conf)
page_check__105 was page_4_check_8 (0.26 conf)
page_check__106 was page_4_check_9 (0.26 conf)
page_check__107 was page_4_check_10 (0.26 conf)
page_check__108 was page_4_check_11 (0.26 conf)
page_check__109 was page_4_check_12 (0.26 conf)
page_check__110 was page_4_check_13 (0.26 conf)
page_check__111 was page_4_check_14 (0.26 conf)
page_check__112 was page_4_check_15 (0.26 conf)
page_check__113 was page_4_check_16 (0.26 conf)
page_check__114 was page_4_check_17 (0.26 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

evaluator_name
users1_address_line_one
city_state_zip
users1_phone_number
email
licensed_practice
license_number
page_field__1
page_field__2
page_field__3
state
patient__1
page_field__4
page_field__5
page_field__6
page_field__7
report_clinical_evaluation
minutes
based_following_information
assessing_date_spent
page_field__8
page_field__9
date_spent_approximately
minutes_patient
patient__2
general_patient_since
page_field__10
page_field__11
page_field__12
page_field__13
page_field__14
page__1
page_check__1
page_check__2
physician_psychiatrist
sources_information
page_check__3
examination_patient
page_check__4
review_patient_records
discussions_patient
discussions_involved_care
family_friends_caregivers
affect_patient_functioning
page__2
excellent
improve
page_check__5
page_check__6
good
fair
poor
stable
decline
uncertain
page_check__7
page_check__8
page_check__9
page_check__10
page_check__11
page_check__12
af_f
page_check__13
page_check__14
page_check__15
page_check__16
page_check__17
page_check__18
page_check__19
page_check__20
page_check__21
page_check__22
page_check__23
page_check__24
page_check__25
page_check__26
page_check__27
page_check__28
page_check__29
page_check__30
page_check__31
page_check__32
page_check__33
page_check__34
page_check__35
page_check__36
page_check__37
page_check__38
page_check__39
page_check__40
page_check__41
page__3
page_check__42
page_check__43
page_check__44
page_check__45
page_check__46
page_check__47
page_check__48
page_check__49
page_check__50
page_check__51
page_check__52
page_check__53
page_check__54
page_check__55
page_check__56
page_check__57
page_check__58
page_check__59
page_check__60
page_check__61
page_check__62
page_check__63
page_check__64
page_check__65
page_check__66
page_check__67
page_check__68
page_check__69
page_check__70
page_check__71
page_check__72
page_check__73
page_check__74
page_check__75
page_check__76
page_check__77
page_check__78
page_check__79
page_check__80
page_check__81
page_check__82
page_check__83
page_check__84
page_check__85
page_check__86
page_check__87
page_check__88
page_check__89
page_check__90
page_check__91
page_check__92
page_check__93
page_check__94
page_check__95
page_check__96
page_check__97
page_check__98
page_check__99
page_check__100
page_check__101
unlikely
possible
probable
almost_certain
factors_increase_decrease
risk
tried_ineffective
users1_signature
signature_date
page_field__15
page__4
supervision__1
supervision__2
hr_supervision
locked_facility
page_field__16
page_field__17
page_field__18
page__5
left_home_person_suitable
mail
hand_delivery
e_filed
page_check__102
left_business_person_charge
page_check__103
page_check__104
page_check__105
page_check__106
page_check__107
page_check__108
page_check__109
page_check__110
page_check__111
page_check__112
page_check__113
page_check__114

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Report on Clinical Evaluation

About This Form:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02