BWhat are the Principal's date of birth and social security number?
AOR01017
This Directive will be effective#for | years.[Other time period]
ADDIOR01
<What is the effective time period of this Advance Directive?
{NEXT_?}
Yes, this Directive will only be effective for a limited time.
ADDIOR01
dWill this Advance Directive remain effective for a time period other than the life of the Principal?
Unless it is revoked or suspended, this Advance Directive shall remain effective during the Principal's lifetime. Enter an X to specify that this Directive will be effective for a limited period of time. The next question asks you to specify the effective time period of this Directive.
kWho will be appointed as your Alternate Health Care Representative? if the first choice is unable to serve?
Enter the name of the Alternate Representative or use the P.I. Manager to select and paste a record. THE ATTENDING PHYSICIAN OR HIS OR HER EMPLOYEE, OR THE OWNER, OPERATOR, OR EMPLOYEE OF A HEALTH CARE FACILITY WHERE THE PRINCIPAL RESIDES OR IS A PATIENT MAY NOT BE THE REPRESENTATIVE UNLESS RELATED TO THE PRINCIPAL.
AOR02019
Special conditions or instructions:#|
ADDIOR02
gWhat instructions or limitations on the Representative's authority should be included in this document?
Enter any limitations on the Representative's authority, or special instructions regarding the location or provision of the Principal's health care.
{NEXT_?}
(CHECK ALL THAT APPLY.)#| Medical records, releases, arrangementsTemporary life supportSpecific Medical ProceduresPregnancyOrgan donationAutopsyFree form option
ADDIOR03
JWhich of the following provisions do you want to include in this document?
Enter an X to include a provision which enables the Representative to request and review health care information, sign releases, and make arrangements for health care. Standard provisions printed in the document regarding life-support and tube feeding if the Principal is in various conditions must be initialed to be effective.
{NEXT_?}
Review medical recordsSign medical record release formsMake health care arrangementsMake decisions regarding admission to or discharge from health care facilitiesSign health care consent or refusal documents
ADDIOR04
Which of the following actions regarding medical records, releases, and arrangements will the Representative be authorized to perform?
{NEXT_?}
ADDIOR05
{NEXT_?}
Artificial/mechanical respirationYesNo
ADDIOR06
<Do you wish to receive artificial or mechanical respiration?
AOR06003
Cardiopulmonary resuscitationYesNo
ADDIOR06
5Do you wish to receive cardiopulmonary resuscitation?
AOR06004
Blood or blood productsYesNo
ADDIOR06
/Do you wish to receive blood or blood products?
AOR06005
Surgery or invasive diagnostic proceduresYesNo
ADDIOR06
MDo you wish to receive any form of surgery or invasive diagnostic procedures?
AOR06006
Kidney dialysisYesNo
ADDIOR06
'Do you wish to receive kidney dialysis?
AOR06007
AntibioticsYesNo
ADDIOR06
#Do you wish to receive antibiotics?
AOR06008
ChemotherapyYesNo
ADDIOR06
$Do you wish to receive chemotherapy?
AOR06009
RadiationYesNo
ADDIOR06
!Do you wish to receive radiation?
AOR06010
#' $(!%)Yes"&*No
ADDIOR06
5What other medical procedures do you wish to receive?
Enter the name of the procedure or treatment the Declarant wishes to receive or not to receive. (You may enter up to 4 other medical procedures.)
AOR06018
AOR06010
Yes, consider current circumstances.
ADDIOR06
+mWill the current circumstances be considered when determining if procedures or treatments should be provided?
Enter an X to include a paragraph containing additional options which consider the circumstances at the time any of the previously listed procedures or treatments are prescribed.
AOR06046
{NEXT_?}
If I am permanently unconscious.If I am suffering from an advanced progressive illness.If such procedures would cause extraordinary suffering.
ADDIOR06
./0xUnder what circumstances do you NOT want to receive the procedures or treatments marked "YES" in the previous questions?
Enter an X if the Principal does not wish to receive the previously listed procedures if he/she is permanently unconscious, except to the extent necessary to provide comfort or pain relief. (CHECK ALL THAT APPLY.)
Enter an X if the Principal does not wish to receive the previously listed procedures if he/she suffers from an advanced progressive illness, except to the extent necessary to provide comfort or pain relief.
Enter an X if the Principal does not wish to receive the previously listed procedures if they would cause the Principal to experience or continue to experience extraordinary suffering.
{NEXT_?}
Representative to determine whether the procedures or treatment should be provided.#| Procedures or treatment should not be provided if the Principal is close to death.
ADDIOR06
What consideration will be given to the current circumstances when determining whether the previously listed procedures or treatments should be provided?
Enter an X if the Principal desires that his/her Representative consider the circumstances at the time any of the previously described procedures are prescribed, and that the Representative determine whether the procedures or treatments should be provided.
Enter an X if the Principal does not wish to receive the previously listed procedures if the Principal's doctor confirms that the Principal is close to death, and life support would only postpone the moment of death.
AOR06020
{NEXT_?}
Yes, if at any point it is determined that it is not possible that the fetus could develop to the point of live birth with continued application of life support, it is my preference that this document be given effect at that point.
ADDIOR07
tIf you have been diagnosed as pregnant, do you desire that this Directive be enforced if the fetus will not survive?
AOR07003
Yes, if life support will be physically harmful or unreasonably painful to me, I request that such harm or pain be considered in determining whether this document shall be effective if I am pregnant.
ADDIOR07
oShould pain or physical harm be considered in determining whether life support should be withheld or withdrawn?
{NEXT_?}
YesNo
ADDIOR08
2Do you want to donate your organs upon your death?
AOR08004
{NEXT_?}
YesNo
ADDIOR08
9Has organ donation been provided for in another document?
AOR08006
{NEXT_?}
Yes, include organ donation desires in this document.
ADDIOR08
RWould you like to specify your desires regarding organ donation in this Directive?
AOR08007
{NEXT_?}
Any needed organs, tissues, or partsSpecific organs, tissues, or parts
ADDIOR08
Which organs are to be donated?
Enter an X if the Declarant authorizes the donation of only certain organs, tissues, or parts. You will be asked to specify the items which may be donated in the next question.
AOR08009
AOR08012
Only the following:#|
ADDIOR08
7What specific organs, tissues, or parts may be donated?
AOR08012
Any purpose permitted by lawOnly for specific purposes
ADDIOR08
.For what purpose are the organs to be donated?
AOR08014
{NEXT_?}
The following purposes:#|
ADDIOR08
QWhat are the limited purposes for which the previously listed organs may be used?
{NEXT_?}
NoYesRepresentative to decide
ADDIOR09
Do you consent to an autopsy?
{NEXT_?}
Other requests or instructions:#|
ADDIOR10
hWhat other requests or instructions regarding your health care do you wish to include in this Directive?
{NEXT_?}
Yes, interpret wishes broadly.
ADDIOR11
\Would you like to request that the wishes expressed in this document be interpreted broadly?
AOR11004
Yes, this document is a formal statement.
ADDIOR11
pIf any provision is not legally enforceable, should this document be taken as a formal statement of your wishes?
AOR11005
Yes, care providers should be morally bound by this document.
ADDIOR11
oIs it your hope that anyone responsible for your care will regard themselves as morally bound by this document?
{NEXT_?}
ADDIOR12
{NEXT_?}
First witness:#|Second witness:#|
ADDIOR13
EWho will witness the Principal's signature on this Advance Directive?
{NEXT_?}
This section requires the signature of the Health Care Representative and the Alternate Health Care Representative to accept their appointment. The Representative(s) agree to act according to the Principal's desires as expressed in this document or otherwise made known by the Principal.
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