Surveypoint

Q1

First Name

Name

Q2

Last Name

Name

Q3

Email

Q4

Phone Number

Q5

Street Address

Address

Q6

Street Address Line 2

Address

Q7

City

Address

Q8

State / Province

Address

Q9

Postal / Zip Code

Address

Q10

A quality of life that is unacceptable to me means (multiple selection possible):

Chronic coma or persistent vegetative state

No longer able to communicate my needs

No longer able to recognize family or friends

Total dependence on others for daily care

Other

Q11

Please select one.

Even if I have the quality of life described above, I still wish to be treated with food and water by tube or intravenously.

If I have the quality of life described above, I do NOT wish to be treated with food and water by tube or intravenously.

Q12

Check the treatments below that you do not want under any circumstances:

Cardiopulmonary Resuscitation (CPR)

Ventilation (breathing machine)

Feeding tube

Dialysis

Other

Q13

Living Will Form -Form Fill

First Name

Last Name

Email

Phone Number

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

A quality of life that is unacceptable to me means (multiple selection possible):

Please select one.

Check the treatments below that you do not want under any circumstances:

When I am near death, it is important to me that: