Healthcare Preferences Worksheet

Healthcare Preferences Worksheet

1. Print this worksheet.
2. Enter the details about your Healthcare Preferences.
3. Make copies for your family, physician, and healthcare agents.
4. Keep the original documents in a safe location.

Healthcare Preferences Worksheet for ____________________________________

Do Not Resuscitate order

Do you have a Do Not Resuscitate order? Yes___ No___

Where are your Do Not Resuscitate documents stored?
Original: ____________________________________________________
Copies: ______________________________________________________

Healthcare providers

Do you have healthcare providers? Yes___ No___

List details for your primary care physician.
Name of physician:
Phone number:
Email:
Address:

List details for each medical specialist.
Name of physician:
Phone number:
Email:
Address:

List details for other healthcare providers.
Name of healthcare provider:
Phone number:
Email:
Address:

Hospice care provider

Do you have a hospice care provider? Yes___ No___

List details for your hospice care provider.
Name of hospice organization:
Phone number:
Address:

Name of hospice nurse
Phone number:
Email:

Name of hospice social worker
Phone number:
Email: