Name Your Medical Decision Maker

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Who Might You Choose?

Can you think of ANY family or friends who MAY be able to make medical decisions for you if you become too sick to make your own decisions?

Yes

I am not sure

Click an answer above to move on

It is OK if you are not ready to choose a medical decision maker.

If you are ready, write the name of your decision maker below. If you prefer a group, write the name of one person who will speak for the group.

Decision Maker #1:

I want this person to make my medical decisions if I am not able to make my own:

First Name

Last Name

Relationship

Decision Maker #2:

If the first person cannot do it, then I want this person to make my medical decisions:

First Name

Last Name

Relationship

2a.

If you want, you can write why you chose your Medical Decision Makers #1 and #2.

2b.

Do you prefer your family and friends make medical decisions for you as a group? If so, who do you want to include in the group?

Is there anyone you would NOT want to make medical decisions for you? If so, write their name and relationship to you here:

It can still be helpful to learn how to ask someone to be a decision maker in case you change your mind in the future.

When do you want your Medical Decision Maker(s) to make medical decisions for you?

I ONLY want my Medical Decision Maker(s) to make medical decisions for me if I become too sick to make my own decisions.

I want my Medical Decision Maker(s) to make medical decisions for me now, EVEN when I can make my own decisions.

I am not sure

If you want, you can write why you feel this way.

If there are decisions you do not want your Medical Decision Maker(s) to make, write them here:

Now it is important to talk to and prepare your Medical Decision Maker(s) for their role.