Your Step 1 Summary

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Review All Step 1 Questions and Your Answers

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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

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:

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: