Yearly Wellness and Directives Update
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.
Email address *
Your name *
Your answer
Relationship to patient *
Phone number *
Your answer
Patient's last name, first initial *
Your answer
Advanced Directive Preference *
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
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.
Your answer
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.
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
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