Form 65 years and older
(Age 65 and older on date of appointment) [MIPS 2025]
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Are you currently in Hospice care?
No
Yes
ADVANCE CARE PLAN: Do you have ANY of the following: Durable Power of Attorney for healthcare, Living will, and/or 'DNR' Do-Not-Resuscitate orders?
No
Yes
Is it against your cultural and/or spiritual beliefs to discuss an Advanced Care Plan (Power of Attorney, Living will, 'DNR') with your medical provider?
No
Yes
Which of the Following Do you Have in Place?
Durable Power of Attorney for Healthcare (Medical)
Living Will
"DNR" Do-Not-Resuscitate Orders
Does ANY of the following describe you: Confined to Wheelchair or Require some assistance when using Wheelchair, unable to walk, or bed ridden?
No
Yes
Falls: Have you had 2 or more falls in the last year Or any fall with injury in the past year?
No
Yes
Submit
Should be Empty: