Get the free Advance Directive Interview Form - Inspira Health Network - inspirahealthnetwork

MR# Acct# DOB Sex Age ADVANCED DIRECTIVE / ORGAN DONATION INTERVIEW Section A: Patient Registration Completes (For Inpatients / Outpatients 18 years and Older) o YES o NO o YES o NO o o o o o 1. Does

How to fill out advance directive interview form

Who needs advance directive interview form?

1. Individuals who want to ensure their wishes for medical treatment and end-of-life care are known and respected.
2. People who have specific preferences or instructions regarding life support, resuscitation, or other medical interventions.
3. Those who want to appoint a healthcare agent to make decisions on their behalf if they become unable to do so.
4. Individuals who want to minimize family conflicts and ensure clear communication about their healthcare preferences.
5. People with chronic illnesses, terminal conditions, or a higher risk of medical emergencies.

How to fill out advance directive interview form:

1. Begin by reading the form carefully and familiarizing yourself with its sections and instructions.
2. Fill in personal information such as your full legal name, date of birth, address, and contact information.
3. Specify your preferred healthcare agent by providing their full name, contact information, and relationship to you.
4. Clearly state your healthcare wishes, including instructions regarding life-sustaining treatment, resuscitation, organ donation, and pain management.
5. Make sure to address different scenarios, such as being in a coma, having a terminal condition, or experiencing irreversible brain damage.
6. If you have specific cultural, religious, or spiritual beliefs that should be considered in your care, include them in the appropriate section.
7. If you have any additional preferences or specific instructions not covered in the form, add them in the designated space or as an attached document.
8. Review the completed form for accuracy and clarity, ensuring that all sections are properly filled out.
9. Sign and date the form in the designated areas. Some forms may require witnesses or a notary public to validate your signature.
10. Make copies of the completed form and distribute them to your healthcare agent, primary care physician, and any other involved healthcare professionals.
11. Keep the original form in a safe and easily accessible place, informing trusted family members or friends of its location.
12. Regularly review and update the form as your preferences or circumstances change, ensuring it remains current and reflects your wishes accurately.

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