Fort Belvoir Will Questionnaire Page 8
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10POWER OF ATTORNEY / LIVING WILL QUESTIONNAIRE
A Living Will makes your wishes known to family and doctors
You
Your Spouse
regarding life support and the following decisions in the event you
Yes
No
Yes
No
become terminally ill or injured with no hope for recovery. Do you
want a living will?
Please answer the following for your Living Will:
If you have a terminal condition, diagnosed by two (2) doctors, do you
want
You
Your Spouse
Yes
Yes
Your life artificially prolonged by machine?
No
No
Yes
Yes
Nutrition and Hydration (Food and Water) by tube?
No
No
Yes
Yes
Blood Transfusions?
No
No
Yes
Yes
Organ Transplants?
No
No
Yes
Yes
Upon your death, do you wish to donate your organs?
No
No
Yes
Yes
For transplants
No
No
Yes
Yes
For science or medical research
No
No
At home Hosp / Nur Home
At home Hosp / Nur Home
Do you wish to die at home rather than in a hospital or nursing home?
A Durable Power of Attorney For Health Care gives broader protection. Do you want to appoint someone (spouse, child, friend) to
make health care decisions for you when you are unable to, but not necessarily terminal? If so provide the following:
For You
For Your Spouse
___________________________________
1st Choice:
Name:_______________________________________
Name:
Address:_____________________________________
Address:_________________________________________
Phone: _____________________________________
Phone: ________________________________________
___________________________________
2nd Choice:
Name:_______________________________________
Name:
Address:_____________________________________
Address:_________________________________________
Phone: _____________________________________
Phone: ________________________________________
A Durable General Power of Attorney appoints an agent that can make any decision and do any act that you can, and it will continue
to be in force even after you become incapacitated. It is a very powerful document and should only be granted with great care, and then only to
a person that you have the utmost trust in. If you wish a Durable General Power of Attorney provide the following
For You
For Your Spouse
1st Choice:
Name:_______________________________________
Name:___________________________________________
Address:_____________________________________
Address:_________________________________________
Phone: _____________________________________
Phone: ________________________________________
2nd Choice:
Name:_______________________________________
Name:___________________________________________
Address:_____________________________________
Address:_________________________________________
Phone: _____________________________________
Phone: ________________________________________
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