Name
*
First Name
Last Name
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Date of Birth
*
MM
DD
YYYY
Healthcare Decision Maker (Agent/Proxy):
*
Do you wish to designate a healthcare decision maker to act on your behalf if you become unable to make medical decisions
If so, please provide their name and contact information.
Healthcare Preferences:
Do you have any specific preferences regarding life-sustaining medical treatments in the event you are unable to communicate your wishes? (e.g., resuscitation, life support, tube feeding)
If yes, please describe your preferences:
Are there specific medical conditions or situations in which you would want or not want certain treatments? (e.g., terminal illness, irreversible coma)
If yes, please describe your preferences:
Quality of Life Preferences:
What is your definition of a good quality of life? Are there specific conditions under which you believe your life would no longer have a good quality?
Religious or Ethical Beliefs
Do you have any religious or ethical beliefs that may affect your end-of-life decisions or preferences? If yes, please explain.
Mental Capacity Assessment
*
Under what circumstances do you believe you should be considered lacking mental capacity to make healthcare decisions?
Review and Updates
*
Do you understand the importance of periodically reviewing and updating your living will to ensure it reflects your current wishes? (Typically recommended every few years or in the event of major life changes)
Witnesses and Notary
re you aware that a living will usually requires witnesses and notarization to be legally valid? Do you need guidance on this process?
Additional Comments
Is there anything else you would like to add or any specific concerns you have regarding your living will or medical decision-making?
