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Personal Directive Questionnaire

Complete the questionnaire below to provide the information needed for your Personal Directive.

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PERSONAL DIRECTIVE QUESTIONNAIRE
1. Name an agent (this is the person(s) that will make personal decisions for you if you lose the capacity to make them for yourself)
2. If you want more than one agent to act together (joint agents), name the other agent or agents here
3. If you are naming more than two agents, do they make decisions on a majority basis or do they all have to agree?
4. If you are not naming joint agents and your first-named agent cannot or will not act, name your second choice here
5. If your second-named agent cannot or will not act, name your third choice here
6. Indicate who should decide whether or not you have lost the capacity to make decisions about any personal matter
7. Do you want to donate your organs and tissue for transplantation purposes if at the time of your death you have any that would be useful for this purpose?
8. What are your views about being kept alive artificially if you have no known hope of recovery?