Questionnaire to Help You Prepare
to See Your Attorney about a Health Care Power of Attorney

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To help you prepare to see your attorney, you may use the following questionnaire to compile information your attorney will need to help you develop an estate plan. Your attorney may prefer to use other questionnaires and may need additional information. Call your attorney before your appointment to see what information he or she may need. You may use the following questionnaire, either by typing your answers directly on the screen or by printing a blank copy and filling out the hard copy. If you choose to type in your answers directly on the screen, print a copy when you are finished. Exiting the program will lose any information you have typed into the questionnaire. Do not try to save your answers in a file because your answers will be erased in the saved file. You will not be asked to transmit your answers over the phone line, so your answers are as secure as your computer. Tip: Print the file often to make sure that you do not lose the information you have entered. Or, fill out a hard copy first, and then enter the information on the computer screen to print.

You have a basic right to control your health care decisions. To make these decisions, you must be competent and able to communicate. If you are not competent or able to communicate, someone else must make these decisions for you. A health care power of attorney allows you to choose this person. The person you choose is your "health care agent." You are the principal.

1. Do you want a health care power of attorney?

Yes No

2. Principal. If you answered "yes," please provide the following information.

Your full name:

Address:
City, State:
Zip:
County:
Home phone number:
Work phone number:

3. Designation of health care agent. Please give the following information about the person you want to name as your health care agent.

Full name of your health care agent:

Address:
City, State:
Zip:
County:
Home phone number:
Work phone number:
Relationship to principal:

4. Designation of alternate health care agents. An alternate health care agent makes your medical decisions when your first choice is not reasonably available or is unable or unwilling to act as your agent. Each alternate health care agent acts alone and successively, in the order named.

Full name of your alternate health care agent:

Address:
City, State:
Zip:
County:
Home phone number:
Work phone number:
Relationship to principal:

Full name of your alternate health care agent:

Address:
City, State:
Zip:
County:
Home phone number:
Work phone number:
Relationship to principal:

5. Designation of doctor. Your health care power of attorney is effective when a doctor states in writing that you lack sufficient understanding or capacity to make or communicate health care decisions. You may name the doctor (or doctors) you want to make this determination. If the doctor you name is unavailable, the doctor taking care of you may determine when your health care power of attorney is effective. If you want to designate a doctor (or doctors) to determine when your health care power of attorney is effective, please provide the following information about your doctor(s).

Full name of your doctor:

Office Address:
City, State:
Zip:
Office phone number:

6. Powers granted to a health care agent. A health care power of attorney gives your health care agent broad powers to make health care decisions for you, including the power to consent to your doctor not giving treatment or stopping treatment necessary to keep you alive. This power exists only when you cannot give informed consent for your medical care.

Appointing someone as your health care agent does not impose a duty on your health care agent to exercise granted powers. However, when your health care agent exercises a power, he or she must act in your best interests following the directions in your health care power of attorney. Because the powers granted by a health care power of attorney are broad and sweeping, you should discuss your wishes concerning life-sustaining procedures with your health care agent.

7. Funeral, cremation, and memorial arrangements. If you want your health care agent to handle funeral arrangements, do you have any special requests about funeral, burial, cremation, or memorial arrangements?

8. Special provisions and limitations. The power granted in a health care power of attorney is intended to be as broad as possible so that your health care agent will have authority to make any decisions you could make to obtain or terminate any type of health care. However, you may limit the scope of your health care agent's powers. You may include any specific limitations you think appropriate such as: your own definition of when life-sustaining treatment should be withheld or discontinued, or instructions to refuse any specific types of treatment that are inconsistent with your religious beliefs, or unacceptable to you for any other reason.

Do you wish to incorporate any of the following documents into your health care power of attorney to give your health care agent additional guidance? Please check all that apply.

Medical guidelines
Medical directive
Advance instruction for mental health treatment

Please list any limitations on your health care agent's powers or other special instructions you want included in your health care power of attorney.

9.Guardianship provision. If the court appoints a guardian of the person (someone to take care of you and your physical needs) or a general guardian (someone to take care of both you and your property), your health care power of attorney will no longer be effective. To protect your choice of health care agent, you may use your health care power of attorney to recommend that the court appoint your health care agent as your guardian of the person if you are declared legally incompetent.

Do you want to nominate your health care agent to be your guardian of the person if a court finds you legally incompetent?

Yes No Not sure

If not, would you like to nominate someone else?

Yes No Not sure

If so, please give person's full name, address, and relationship to you.

Full name of your recommended guardian of the person:

Address:
City, State:
Zip:
County:
Home phone number:
Work phone number:
Relationship to principal:

10. End of life decisions. Do you want to give your health care agent the power to give your doctor permission to withhold or discontinue life-sustaining treatment?

Yes No

11. Living will. Do you have a living will?

Yes No

12. Revocation. You may revoke your health care power of attorney at any time while you can make and communicate your medical care decisions. The revocation may be in writing or by any means that you can communicate your intent to revoke to your doctor and your health care agent. Also, you revoke a health care power of attorney by signing another health care power of attorney. Revocation is effective only after you have notified your doctor and each named health care agent. Finally your death revokes your health care power of attorney.

Have you signed a health care power of attorney before?

Yes No

Any other comments or questions about your health care power of attorney?

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Prepared by Carol A. Schwab, J.D., LL.M.
Professor and Extension Specialist, NC State University.

This publication is provided as a public service and is designed to acquaint you with certain legal issues and concerns. It is not designed as a substitute for legal advice, nor does it tell you everything you may need to know about this subject. Future changes in the law cannot be predicted, and statements in this publication are based solely on the laws in force on the date of publication.

WARNING: This questionnaire is designed to help your attorney prepare the appropriate legal document. Providing answers to the questionnaire has no legal effect and is not a substitute for the legal document itself.

Date: August 2000