Va Advance Directive: Durable Power Of Attorney For Health Care And Living Will Page 4
Download a blank fillable Va Advance Directive: Durable Power Of Attorney For Health Care And Living Will in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Advance Directive: Durable Power Of Attorney For Health Care And Living Will with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7VA ADVANCE DIRECTIVE: DURABLE POWER OF ATTORNEY FOR HEALTH CARE AND LIVING WILL
NAME (Last, First, Middle)
SOCIAL SECURITY NUMBER
Yes.
I'm not sure. It
No.
I would want
would depend
I would not want
life-sustaining
on the
life-sustaining
treatments.
circumstances.
treatments.
If I have a permanent condition where other people
Initials
Initials
Initials
must help me with my daily needs (for example,
eating, bathing, toileting).
Initials
Initials
Initials
If I need to use a breathing machine and be in bed
for the rest of my life.
Initials
Initials
Initials
If I have pain or other severe symptoms that cause
suffering and can't be relieved.
Initials
Initials
Initials
If I have a condition that will make me die very soon,
even with life-sustaining treatments.
Other:
Initials
Initials
Initials
B - MENTAL HEALTH PREFERENCES
This section is optional. You may skip this section if you do not have a serious mental health problem or if you
do not want to write down your preferences for mental health care. If you have a serious mental health
condition, you might want to write down medications that have worked for you in the past and that you would
want again, or you might want to write down the mental health facilities or hospitals that you like and those
that you don’t like. If you need more space, you may attach extra pages and use this space to refer to
attached pages. Be sure to initial and date every page that you attach.
VA FORM
10-0137
Page 4 of 7
JUL 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical