Estate Planning_Advance Directive Questionnaire

Advance Directive Questionnaire

Theinformation requested below is essential in preparing your Advance Directive. If both you and your spouse require estate planning documents, you will need to each fill out a separatequestionnaire.
Basic Personal Information

Fill out this section for yourself.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Mobile Phone
Date of Birth

MonthDayYear
Date
Health Care Matters Appointee(s)

Who do you wish to appoint to handle all Health Care matters on your behalf if you are unable to do so on your own?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the Appointee named above cannot or will not serve in that capacity, who do you wish to name as the successor Appointee?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If the first successor Appointee named above cannot or will not serve in that capacity, who do you wish to name as the second successor Appointee?
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Legal Permissions
1. Do you grant your agent the right to demand an autopsy?

YESNO
2. Do you grant your agent the right to cause your organs to be donated?

YESNO
3. I want my body to be Buried or Cremated:

BURIEDCREMATED
4. Do you grant your agent the right to demand an answer to Question #1, above?

YESNO
5. If I cannot communicate my wishes or If I am in a vegetative state, I want all medical means and machines available utilized to keep me alive regardless of my condition or the likelihood of my recovery?

YESNO
6. If I cannot communicate my wishes or If I have a terminal condition (which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time), I want all medical means and machines available utilized to keep me alive regardless of my condition or the likelihood of my recovery?

YESNO
7. If I cannot communicate my wishes or If I am in a vegetative state, I want no action taken or medical means utilized to keep me alive in order to allow my natural death to occur?

YESNO
8. If I cannot communicate my wishes or If I have a terminal condition (which means I have an incurable or irreversible condition that will result in my death in a relatively short period of time), I want no action taken or medical means utilized to keep me alive in order to allow my natural death tooccur?

YESNO
9. If I cannot communicate my wishes and I am in either a vegetative state or have a terminal condition, do not take any action that might cure me or extend my life, including machines and treatment, except (check if you want any of these statements to apply):

If I cannot take food/nutrition by mouth, I want to receive nutrition by tube or other medical means.If I cannot take liquid/hydration by mouth, I want to receive fluids by tube or other medical means.If I cannot breathe, I want to have a ventilator used.
10. IN CASE OF PREGNANCY, GENERALLY NUMBERS 5-9 WILL HAVE NO FORCE AND EFFECT UNLESS THE FETUS IS NOT VIABLE. I INDICATE BELOW THAT I WANT IT TO BE CARRIED OUT IF THE FETUS IS NOT VIABLE.

YESNO
NOTE: Question 11 (below) need not be answered unless you want to name a guardian for yourself.
11. If I cannot make decisions for myself and a court decides I need a Guardian appointed, I hereby nominate the person appointed as my Health Care Agent herein:

YESNO
If Question 11 (above) is answered "NO", I nominate the following person:
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Effect

When do you wish these wishes to take effect?
I wish my above-stated wishes to immediately take effect:

YESNO
If "NO", I wish my above-stated wishes to take effect on the following date:

MonthDayYear
Date
Should be Empty:

Advance Directive Questionnaire

Basic Personal Information

Health Care Matters Appointee(s)

Legal Permissions

Date of Effect