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California Advance Health Care Directive Questionnaire

Please fill out the following requested information. This information will be used to complete your California Advance Health Care Directive.

Please note that all fields followed by an asterisk must be filled in.

Full legal name*

Other names you use (optional)

Home address*

Best phone number*

County of residence*

Email*

Who do you want to make health care decisions for you if you are unable to? (include name, relationship, address, phone)*

If the above person cannot make decisions for you, who is your second choice? (include name, relationship, address, phone) (optional, but highly recommended)

If the above two people cannot make decisions for you, who is your third choice? (include name, relationship, address, phone) (optional)

When do you want your agent to be able to make health care decisions for you IF you are unable to?*

	Immediately (recommended)
	When my primary care physician determines I am unable to make my own decisions

This statement will be included in your Advance Health Care Directive: “I direct that my health care providers and others involved in my care provide, withhold, or withdraw treatment in accordance with the choice I have marked below.” Please choose (a) or (b)*

	(a) Choice Not to Prolong Life: I do not want my life to be prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time, (2) I become unconscious and, to a reasonable degree of medical certainty, I will not regain consciousness, or (3) the likely risks and burdens of treatment would outweigh the expected benefits, OR
	(b) Choice to Prolong Life: I want my life to be prolonged as long as possible within the limits of generally accepted health care standards.

Upon your death, do you wish to make anatomical gifts?*

	Yes
	No

Do you wish to give your agent the authority to authorize an autopsy?*

	Yes
	No

Do you wish to give your agent the authority to direct the disposition of your remains?*

	Yes
	No

If you wish to designate a primary physician, please provide name, address and phone number. (optional)

If you wish to designate an alternate physician if your primary physician is not available, please provide name, address and phone number. (optional)

HIPAA Waiver: Your agent will have the authority to view your medical records. Is there anyone else you would like to be able to see your medical records? If so, please provide their (1) name, (2) relationship to you, (3) address, and (3) best phone number. (optional)

Who referred you to my office?*

Have you read and signed the "Limited Engagement Letter and Terms of Engagement"?*

Yes

Please enter the word that you see below.

California Advance Health Care Directive Questionnaire

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