1. How did you hear about the Health Care Decisions Web site?

    From a family member / friend
    From my doctor
    From a health care professional (like a nurse or social worker)
    From "surfing the net"
    I attended a presentation.
   When & Where: 
   Other: 

2. Did you have an Advance Directive before you saw this Web site?

    Yes
    No

2a. If no, why not?

    I didn't know about Advance Directives
    I didn't want to talk about it
    I didn't think I needed one
    I didn't take the time to complete one
    I didn't know how to complete one
   Other: 

2b. If yes, what forms do you have:

    A Living Will
    A Health Care (Medical) Power of Attorney
    Other Health Care Directive

3. Do you plan to use the Health Care Decisions Advance Directive forms from this Web site?

    Yes, I plan to use these forms from this web site.
    No, I already have forms
   No, I will not use these forms because:
   

4. Why are you interested in this Web site at this time?

    I heard a talk on Advance Directives
    I talked to a family member / friend about Advance Directives
    A family member / friend of mine is sick now
    I am sick now
   Other: 

5. Did you find this site helpful?

    Yes
    No

6. Tell us about yourself:

6a. Age

     under 21 years old
    21 to 45 years old
    46 to 65 years old
    66 to 75 years old
    over 76 years old

6b. Sex

    Male
    Female

6c. Race / Ethnicity

6d. Marital Status

    Single
    Married
    Divorced

7. May we contact you if we have questions about this survey?

Name: Address: Phone: Email address:

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