Advance Directive for Dementia Care
Personal Information
Full Name
Date of Birth
Address
Phone
Date of Directive
Healthcare Agent / Proxy
Name
Phone
Relationship
Dementia Care Preferences
I consider myself to have advanced dementia when
I do/do not want the following medical treatments
Tube Feeding (Artificial Nutrition & Hydration)
Hospitalization / Emergency Room Care
Pain & Symptom Management Preferences
Living Arrangements & Social Preferences
Preferred Living Arrangements
Preferences on Visitors/Social Activities
Other Instructions
Additional Requests or Instructions
Signatures
Signature
Date