Yearly Wellness and Directives Update

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This form is for the DPOA (Durable Power of attorney)
Who has legal medical decision rights for the patient.
It helps us update, educate, and organize information quickly,
And will be verified for accuracy with the DPOA on file.
At least once per year, please update us with your preferences.
Preference can always be changed.

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メールアドレス *

Your name *

Relationship to patient *

Son or Daughter

Spouse

Other Family

その他:

Phone number *

Patient's last name, first initial *

Advanced Directive Preference *

(1) prefer to not go to the hospital, no matter what. Treat symptoms with comfort medication only. (If this option is preferred, please contact us about palliative or hospice care options)

(2) go to the hospital to diagnose and stabilize but use medications only, comfort care only if continues to worsen.

(3) go to hospital, treatment to include ventilator/artificial breathing up to 2 weeks if needed, but no aggressive CPR. (This option is often preferred when a person is stable, has quality of life, and would like a chance to recover for something like pneumonia or surgery)

(4) go to hospital with treatment to include ventilator for prolonged period if needed, but no aggressive CPR. or

(5) go to hospital with treatment to include ventilator and aggressive CPR (defibrillator, chest compressions, intubation - FULL CODE, low rate of survival, high rate of suffering in the elderly)

その他:

必須

Other Preventative Recommendations - May not be relevant due to age or conditions, but please check if you would like to arrange, or if you would like more information

Colorectal Cancer Screen - every 10 years, up to 80 years old

Osteoporosis Screen - every 1-2 years, after 65 years old

Breast Cancer Screen - Mammogram - Females age 50-74

I'm considering but would like more information

その他:

We often add new services, education, and improvements through email newsletter. Let us know additional email addresses for family members to also get updates. You may opt out at any time.

Would the patient possibly benefit from in-house specialist consultation? Please note this is for planning purposes and service may not be available in the patient's area. Check as many are needed.

Yearly eye exam (opthlamologist)

Cardiologist evaluation (may include medication review, electrocardiogram, echocardiogram, results sent to 'regular' cardiologist if needed)

Orthopedic evaluation (may perform arthritis joint injection, evaluation of bone or joint condition)

Podiatrist evaluation (may evaluate foot problems, diabetic toenail trimming)

Neurology (evaluate dementia, sleep disorders, neuropathy)

Nephrology (evaluate kidney and electrolyte conditions)

Dermatologist (evaluate skin conditions)

Definitely

Maybe

その他:

Depression Screening

Not at all

Several days

More than half the days

Nearly every day

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself - or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or of hurting yourself in some way

Not at all

Several days

More than half the days

Nearly every day

Little interest or pleasure in doing things

Feeling down, depressed, or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself - or that you are a failure or have let yourself or your family down

Trouble concentrating on things, such as reading the newspaper or watching television

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or of hurting yourself in some way

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