Will Questionnaire

Power of Attorney Questionnaire

Health Care Directive Questionnaire

Advice Following
the Signature of Your Will

Health Care Directive (Living Will) Questionnaire

A Health Care Directive is a document executed by a competent individual concerning health care decisions to be made in the event that the individual becomes incompetent to make such decisions. There are three types of Health Care Directives. A general directive does not clearly anticipate and give direction relating to treatment for the specific circumstances that exist but is used for guidance as to the wishes of the person. A specific Health Care Directive clearly anticipates and gives directions relating to the treatment for the specific circumstances that exist. This type of Health Care Directive has the same effect as a health care decision made by a person with full capacity to make and communicate such a decision concerning a specific proposed treatment. Finally, you may appoint a proxy, a person who is given the power to make health care decisions for you.

Your name -


- General Directive


- Specific Directive:

- Appoint a Proxy:

Name -
Relation -
City/Town -
Phone Number -

Health Care Information:

Name of Doctor -
Phone Number -

Completing this form does not constitute a valid Health Care Directive. The information will be used to complete a Health Care Directive for you which will become valid once properly executed.