Questionnaire for  

1. Your Name*:      

2. Your Gender*:    Male  Female

If you are a female, are you pregnant now, or is it physically possible that you could become pregnant in the future?

         No      Yes  

3. Your State.*                 

4. Doctor Information (Name, Address, Phone #):

   1st Choice:        

   2nd Choice:       

 

5. Health Care Agent (Name, Relationship, Address, Phone#):

   1st Choice:

  2nd Choice:

6. Authorization Limits*:

  a. life support:             Yes       No

  b. food and water:       Yes       No

  c. organ donation :       Yes       No

 d. consent to autopsy:   Yes       No    Agent's Decision   

  e. burial or cremation:    

      I expressed this wish in this document:  

              I give my agent this authority:          

7. Guardian Choice*:  

 I want my health care agent to be also my Guardian:        

8. Specific Health Care Wishes*:

 None, I want my agent to make all health care decisions for me.

  Yes, as follows:

        A. Terminal Condition

          I do not want any life support;

                          Food and Water:

          I want some life support, as checked below:

                    Blood and blood products

                    CPR-cardiopulmonary resuscitation

                    Dialysis

                    Drugs, other than pain relievers

                     Diagnostic Tests

                     Artificial Respirator

                     Complicated Invasive Surgery

                         Food and Water: 

            I want all possible life support

            I want my agent to decide

        B. Permanent Unconsciousness.

          I do not want any life support;

                          Food and Water:

          I want some life support, as checked below:

                    Blood and blood products

                    CPR-cardiopulmonary resuscitation

                    Dialysis

                    Drugs, other than pain relievers

                     Diagnostic Tests

                     Artificial Respirator

                     Complicated Invasive Surgery

                         Food and Water: 

            I want all possible life support

            I want my agent to decide

9. Additional Wishes:

            Location of care:        

            Comfort care:             

            Pain Relief Exceptions:

            Personal or Religious Values:

            Other Wishes:             

10. Pregnancy (for women): 

            I want my heath care wishes enforced

            I don't want my health care wishes enforced

11. Specific Wishes Regarding Organ Donation*:

   I expressed these wishes in this document:

   I want to leave these specific instructions:

           I want to donate any needed organs, tissue, or body parts

           I want to donate only the following:

           What I donate can be used for any lawful purpose

           What I donate can be used only as follows:

                    Research        Education

                    Therapy          Transplant

    I do not want to donate any of my organs, tissue or body parts

    I do not wish to make any statement regarding organs, tissue or  body parts donation after my death

Please tell us how did you hear about us?* 

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Your Contact Info: Email:   

                               Phone:  

Terms of Use:* I read and I agree with the Terms of Use agreement.            Yes, I agree.  No, I don't agree.

Please review your answers carefully before clicking the Submit button below!  Thank you.

                                                                       

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