QUESTIONNAIRE OF INFORMATION NEEDED BY YOUR LAWYER TO DRAFT POWER OF ATTORNEY FOR PERSONAL CARE (MEDICAL DECISIONS)

  1. NAME OF PERSON(S) YOU WOULD LIKE TO APPOINT AS YOUR PERSONAL CARE ATTORNEY(S) OR AGENT(S): (ATTORNEY DOES NOT MEAN A LAWYER IN THIS CASE.) ________________________________________________________________________________________________________________________________________________________________________________
  2. IF YOU HAVE CHOSEN 2 PEOPLE TO BE YOUR ATTORNEYS SHOULD THEY ACT JOINTLY OR JOINTLY AND SEVERALLY?: ________________________________________________________________________________________________________________________________________________________________________________
  3. NAME(S) OF PERSON(S) YOU WOULD LIKE TO ACT AS SUBSTITUTE ATTORNEY(S): ________________________________________________________________________________________________________________________________________________________________________________
  4. IF YOU HAVE CHOSEN 2 PEOPLE TO BE YOUR SUBSTITUTE ATTORNEYS SHOULD THEY ACT JOINTLY OR JOINTLY AND SEVERALLY? ________________________________________________________________________________________________________________________________________________________________________________
  5. ARE THERE ANY RESTRICTIONS OR EXCEPTIONS? ________________________________________________________________________________________________________________________________________________________________________________
  6. DO YOU HAVE A PREFERRED DOCTOR TO PERFORM ANY ASSESSMENT OF YOUR CAPACITY TO UNDERSTAND AND MAKE MEDICAL DECISIONS? (NAME AND ADDRESS): ________________________________________________________________________________________________________________________________________________________________________________