Patient Health Risk Assessment Template Page 2
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1
2Patient Name:
_____________________________________________
Page 2
ADVANCE DIRECTIVES
To make sure that an incapacitated person’ s decisions about health care will still be respected, the Florida legislature
enacted legislation pertaining to health care advance directives. This is a written or oral statement about how you
want medical decisions made should you not be able to make them yourself. The best time to do this is when you
are healthy and well. The three main types are: 1. A Living Will, 2. A Health Care Surrogate Designation and
3. A Durable Power of Attorney.
Which document(s) do you have?
_______________________________________________________________
(Please provide a copy of the document(s) to your Primary Care physician.)
COMMENTS
Patient:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Physician:
__________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
*** OFFICE USE ONLY ***
O
O
Old records requested:
Yes
No
If yes, date requested: _____/_____/_____
Doctor: ___________________________________
Hospital: ___________________________________
Address: ___________________________________
Address: ____________________________________
__________________________________________
___________________________________________
__________________________________________
___________________________________________
O
O
Reviewed EOL with patient:
Yes
No
Date: _____/_____/_____
O
Received:
Living Will
Date: _____/_____/_____
O
Designation of Health Care Surrogate
Date: _____/_____/_____
O
Durable Power of Attorney
Date: _____/_____/_____
Physician Review: _____________________________________________________ Date: _____/_____/_____
PLEASE RETURN TO YOUR PHYSICIAN
NP3: 03/11
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