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Interviewer instructions:

For all questions, read both the bold text and examples to the interviewee. Click “Record” below each question to capture a video of the answers.

Who would you want to make health decisions for you if you became incapacitated?
(specify full name(s), relationship(s), and how to best reach them)

RECORD PLAY DELETE SAVE

If you suddenly keeled over, had no heartbeat, and were not breathing, what would you want done?
(for example “Call 911” or “Call the undertaker”)

RECORD PLAY DELETE SAVE

Describe your feelings about having a PERMANENT feeding tube if you weren’t able to eat for yourself.
(for example “I want one to keep me alive even if I’m unconscious and unlikely to recover” or “I never want to have a permanent feeding tube”)

RECORD PLAY DELETE SAVE

Describe your feelings about having a TEMPORARY feeding tube if you weren’t able to eat for yourself.
(for example “I want one if there is a chance my condition will improve” or “I never want to have even a temporary feeding tube”)

RECORD PLAY DELETE SAVE

Describe your feelings about being put on a PERMANENT breathing machine if you weren’t able to breathe for yourself.
(for example “I want one to keep me alive even if I’m unconscious and unlikely to recover” or “I never want to be put on a permanent breathing machine”)

RECORD PLAY DELETE SAVE

Describe your feelings about being put on a TEMPORARY breathing machine if you weren’t able to breathe for yourself.
(for example “I want one if there is a chance my condition will improve” or “I never want to be put on even a temporary breathing machine”)

RECORD PLAY DELETE SAVE

Give at least one specific example explaining why you made the choices above.
(for example “My husband had a feeding tube against the advice of others and he made a complete recovery” or “My aunt suffered greatly on a breathing machine and never got better before she died”)

RECORD PLAY DELETE SAVE

Finalize

PLAY ALL CONFIRM & SIGN

Share

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Notes:
1. Must be HIPAA compliant for health care use.
2. Need record, play, delete, and save capabilities.
3. Must be able to save files on my server.
4. Need capability to retrieve files from my server.

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