Decisions for Dignity (Pre-Survey)
I understand why End-of-Life planning is important for me.
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I am worried about my care if I am no longer to make my own decisions.
*
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
I have a trusted person who can help me make medical and End-of-Life decisions.
*
Yes
No
Unsure
If yes, please indicate your relationship to your trusted person:
My Family/Advocate/Trusted person knows my End-of-Life wishes.
*
Yes
No
Unsure
My doctor(s) is aware of my End of Life wishes.
*
Yes
No
Unsure
I already have the following legal documents in place:
Durable Power of Attorney
*
Yes
No
Unsure
Healthcare Power of Attorney
*
Yes
No
Unsure
HIPAA Authorization
*
Yes
No
Unsure
Advanced Directives & Living Will
*
Yes
No
Unsure
Out of Hospital DNR
*
Yes
No
Unsure
In the last 6 months, I have scheduled an appointment for End-of-Life planning.
*
Yes
No
Unsure
If yes, what entity or individual did you meet with?
I would like more information about creating an end-of-life plan.
*
Yes
No
Unsure
Submit
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