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Health Care Directive Questionnaire
First name
*
Middle Name(s)
Last name
*
Address
*
Agent
Name an Agent
*
Agent's Phone
*
Agent's Email
*
Agent's Address
*
Select the sentence you agree with:
*
My Agent can make decisions for me immediately.
My Agent will make decisions for me only after I cannot make my own decisions.
How do you want your Agent to follow your healthcare wishes?
*
Total Flexibility: It is OK for my Agent to change any of my medical decisions if my doctors think it is best for me at that time.
No flexibility: I want my Agent to follow my medical wishes exactly, no matter what. It is not OK to change my decisions, even if the doctors recommend it.
Some Flexibility: It is OK for my Agent to change some of my decisions if the doctors think it is best. But, these are some wishes I never want changed:
Some Flexibility
Health Care Choices
My life is only worth living if I can (select all that apply):
talk to family or friends
wake up from a coma
feed, bathe, or take care of myself
be free from pain
live without being hooked up to machines
my life is always worth living no matter how sick I am
I am not sure
Other
If I am dying, it is important for me to be:
at home
in the hospital
not sure
What should your doctors know about your religious or spiritual beliefs?
Select the sentence you most agree with:
If I am so sick that I may die soon,
try all life support treatments that my doctors think might help. If the treatments do not work and there is little hope of getting better, I want to stay on life support machines even if I am suffering.
try all life support treatments that my doctors think might help. If the treatments do not work and there is little hope of getting better, I do NOT want to stay on life support machines. If I am suffering, I want to stop.
I do not want life support treatments, and I want to focus on being comfortable. I prefer to have a natural death.
I want my Agent to decide for me.
I am not sure.
Select the sentence you most agree with:
I want to donate my organs.
I do not want to donate my organs.
I want my Agent to decide.
I am not sure.
If you wish to donate, which organs?
Any organs
Only these organs:
Select the sentence you most agree with:
I want an autopsy.
I do not want an autopsy.
I only want an autopsy if there are questions about my death.
I want my Agent to decide.
I am not sure.
Do you have any specific funeral or burial wishes?
What other wishes are important to you?
Submit
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