Fill and Sign the Advance Directives University of Utah Health Form

Living Will – Advanced Health Care Directive Questionnaire Your name: Address: Home phone: Work phone: Cell phone: Birth date: Do you wish the living will to take effect now or only if you are disabled or incapacitated? Duration of living will to be: Do you wish to appoint a conservator? Yes No If yes, please provide name, address, and phone number: Do you wish to be kept on artificial life support? Yes No Which of the following do you consider to be a "terminal condition”: An incurable and irreversible condition that requires life support A permanent coma A persistent vegetative state Do you want food & water administered if you are in terminal condition? Yes No Do you want any limitations on pain medication? Yes No If yes, describe: Do you wish to donate organs? Yes No If yes, for what purpose(s)? Transplant Education Research Therapy Who would you like to make the donation to? A particular physician: Alternate physician A medical facility: A specific donor: Alternate donor Any person or entity What would you like to donate? TISSUE: Eyes Bone and connective tissue Skin Heart Other: ORGAN: Heart Kidney(s) Liver Lung(s) Pancreas Other: Will you appoint an individual to make health care decisions for you? Yes No If yes: Name of Health Care Representative: Relationship: Age: Address of Representative: Phone Number of Representative: Will the Representative benefit in any way by your death (beneficiary in your will, insurance policy, etc.)? Yes No If yes, please describe: Will you appoint an alternate individual to make health care decisions for you if the person above is unable, unavailable, or unwilling to act? Yes No If yes: Name of alternate Health Care Representative: Relationship: Age: Address of alternate Representative: Phone Number of alternate Representative: Will the alternate Representative benefit in any way by your death (beneficiary in your will, insurance policy, etc.)? Yes No If yes, please describe: Do you wish to name a primary physician? Yes No If yes: Physician’s name: Address: Phone number: Do you wish to name an alternate primary physician? Yes No If yes: Physician’s name: Address: Phone number: Will personal representative be able to authorize the disposal of body remains? Yes No Will Personal Representative be able to authorize an autopsy? Yes No If there are any health care decisions you do not wish the Representative to make, please describe: Do you wish the living will to express a desire to die at home rather than in a hospital? Yes No Do you wish the living will to express a desire to die at a hospice or other particular location rather than in a hospital? Yes No If yes, please describe; Do you wish to express desires regarding funeral arrangements? Yes No if yes, please describe: If you have any further health care instructions, please describe: