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Healthcare Essentials Worksheet
1. Print this worksheet.
2. Enter the details about your Healthcare Advance Directives.
3. Make copies for your family, physician, and healthcare agents.
4. Keep the original documents in your End-of-Life Binder.
Healthcare Essentials Worksheet for ________________________________
Advance Directive - Durable Power of Attorney for Healthcare
Do you have a Durable Power of Attorney for Healthcare?
Yes___ No___
Where is your Durable Power of Attorney for Healthcare stored?
Original: _____________________________________________________
Copies: ______________________________________________________
Who is your health care agent?
Name: _______________________________________________________
Phone number: ________________________________________________
Email: _______________________________________________________
Address: _____________________________________________________
Relationship: __________________________________________________
Alternate health care agent
Name: _______________________________________________________
Phone number: ________________________________________________
Email: _______________________________________________________
Address: _____________________________________________________
Relationship: __________________________________________________
Advance Directive - Living Will
Do you have a Living Will?
Yes___ No___
Where is your Living Will stored?
Original: _____________________________________________________
Copies: ______________________________________________________
Primary Care Physician
List the details for your primary care physician.
Name of physician: _____________________________________________
Phone number: ________________________________________________
Email: _______________________________________________________
Address: _____________________________________________________
Relationship: __________________________________________________