Durable Health Care Power Of Attorney Questionnaire Template printable pdf download

DURABLE HEALTH CARE POWER OF ATTORNEY QUESTIONNAIRE

ATTORNEY WORK PRODUCT/ ATTORNEY-CLIENT PRIVILEGED INFORMATION

Full Legal Name: __________________________________________________________________________________

Address: ________________________________________________________________________________________

City: _________________________________ State: ___________________ ZIP:

________________________

Cell: _______________________________ Other: ________________________ Fax: _______________________

E-Mail: _____________________________________ DOB:

_____________________________________

The Durable Health Care Power of Attorney lets you choose an agent and an alternate agent to make health care

decisions if you can no longer make those decisions for yourself. It also specifically outlines what decisions your agent

can and cannot make for you. It can even outline autopsy, organ donation, and burial/cremation preferences. I am not

recommending any particular choices in this questionnaire. Before answering these questions, you should think about

your agent and alternate agent choices. You should likewise consider what medical treatments you want and/or do not

want to authorize your agent to make on your behalf. If you have any questions regarding these questions, please talk to

your doctor about what the terms mean or leave the question blank and we will discuss the item further. Otherwise,

please indicate your desires in this questionnaire and return it so that your Durable Health Care Power of Attorney can be

drafted for your review.

Selection of Your Health Care Representative (Agent):

I choose the following person to act as my representative to make health care decisions for me (If married, usually

spouse):

Full Legal Name: __________________________________________________________________________________

Address: ________________________________________________________________________________________

City: _________________________________ State: ___________________ ZIP:

________________________

Cell: _______________________________ Work: ________________________ Home: _______________________

I choose the following person to act as my alternate representative to make health care decisions for me if my first

representative is unavailable, unwilling, or unable to make decisions for me:

Full Legal Name: __________________________________________________________________________________

Address: ________________________________________________________________________________________

City: _________________________________ State: ___________________ ZIP:

________________________

Cell: _______________________________ Work: ________________________ Home: _______________________

Durable Health Care Power Of Attorney Questionnaire Template