Living Will
Program Evaluation
Date:_______________ Location:__________________
YES NO
1. I have a living will (declaration)
2. If you checked yes on #1, my living will form:
a. was written by an attorney
b. given to me by a hospital
c. copied off the Internet
d. from the MSU Extension MontGuide “Montana Rights of
Terminally Ill Act”
e. other, please describe:
___________________________________________________________
___________________________________________________________
___________________________________________________________
3. I have given a copy of my living will (declaration) to:
Check all that apply:
a. my physician
b. my children
c. other family members
d. a friend
e. other, please list:
___________________________________________________________
___________________________________________________________
___________________________________________________________
4. I plan to use the form in MSU Extension MontGuide as my living will.
5. I plan to have an attorney write my living will.
6. I plan to use a form printed from the Internet as my living will.
7. I will encourage other family members and friends to have a living will.
8. I plan to seek further information on advance directives.
9. I plan to have my attorney write a health care power of attorney for me.
10. Other: Describe other actions you plan to take as a result of the program on living wills.
11. What was the most important fact you learned during the program?
12. What suggestions do you have for improvement, when this class is offered again?
C://Data/Marsha-G/Evaluations/livingwill.doc/05/30/07/kh