Power of Attorney Questionnaire

Full Name *:

Email Address *:

Address *:

County *:

Telephone Number *:

Healthcare Matters

Designation of Primary Agent

Note: This individual will make all heath-care decisions for you.

Agent's Full Name:

Agent's Address:

Agent's County:

Agent's Telephone Number:

Agent's Relationship to You:

Designation of Alternate Primary Agent

Agent's Full Name:

Agent's Address:

Agent's County:

Agent's Telephone Number:

Agent's Relationship to You:

Mark the choice that applies to you

Choice To Prolong LifeChoice NOT To Prolong Life

If you choose not to prolong life, and you are diagnosed with a terminal illness with no hope of
recovery, please mark which options apply:

Cardiac Resuscitation
DoDo NOT

Mechanical Respiration (Artificial Breathing)
DoDo NOT

Tube Feeding
DoDo NOT

Antibotics
DoDo NOT

Pain Relief
DoDo NOT

Maintained in a Vegetative Condition
DoDo NOT

Additional Wishes: