Capacity Evaluation

[YOUR COMPANY NAME]

Patient Information:

Name
Age
Date of Evaluation
Evaluator

Introduction

This form serves as a systematic approach to assess a patient's capacity for decision-making regarding health care and financial management.

Overview

This evaluation will be conducted in a comprehensive and precise methodology to ensure accurate findings. Results will contribute decisively to the patient's care and treatment plans.

Evaluation Criteria

1. Knowledge: Measures the patient's understanding of their medical condition, prospective treatment, financial responsibilities, and potential outcomes.

2. Reason: Ability to weigh the benefits and drawbacks of alternative solutions for their medical and financial management.

3. Appreciation: Assesses whether the patient comprehends the personal implications and consequences of their decisions.

4. Choice: Determines if the patient is capable of communicating their decisions clearly and consistently.

Evaluation Table

Evaluation Criteria	Description	Score (1-5)
Knowledge	Can the patient accurately define and understand their medical or financial situation?
Reason	Does the patient adequately weigh the benefits and risks of their options?
Appreciation	Can the patient comprehend the personal implications and consequences of their choices?
Choice	Can the patient communicate their decisions clearly and consistently?

Scoring: 1 (Poor), 2 (Fair), 3 (Good), 4 (Very Good), 5 (Excellent)

Additional Notes and Comments

Comments

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