name / week: ________________health care proxy worksheet
this worksheet is not a legal document. the form that legally appoints a proxy is specific to your state or country and usually free from your health department, hospital or doctor. use this to prepare, then complete the official form.
| item | details |
|---|---|
| my health care proxy (name) | |
| relationship to me | |
| phone | |
| backup proxy (name) | |
| backup phone | |
| my doctor and practice | |
| conditions and allergies they must know | |
| medications i take | |
| treatments i would want | |
| treatments i would not want | |
| what matters most to me | |
| who should be told | |
| where my signed legal form is kept | |
| date of this worksheet |
free worksheet from rox · talktorox.com · not medical advice
the free symptom tracker does the same job in your browser and works out the patterns for you. rox is the free ios app behind it: it remembers every entry, reads your apple watch, oura, garmin or amazfit, and builds a summary a doctor can read in a minute.
how to use it
A health care proxy, also called a health care agent or medical power of attorney, is the person who makes medical decisions for you if you cannot make them yourself. Naming one legally requires a form specific to where you live. This worksheet is the step before that: working out who, and what you would want them to say.
The hard part is rarely the paperwork. It is deciding what matters to you and telling the person, clearly, before it is urgent. A proxy who has never discussed your wishes is being asked to guess, which is a heavy thing to hand someone.
With a chronic illness this is worth doing early and revisiting. Write it while you are well, keep it with your medication list and medical history, and tell your proxy where it is. Update it after any significant change in your health or your relationships.
Once you have completed the official form, note where the signed copy is kept. A legally valid document nobody can find is the most common way this fails.
01
what is a health care proxy?
a health care proxy is a person you legally appoint to make medical decisions for you if you become unable to make them yourself. depending on where you live they may be called a health care agent, health care representative or medical power of attorney.
02
is this worksheet a legal health care proxy form?
no. this is a preparation worksheet. the document that legally appoints a proxy is specific to your state or country, and is usually available free from your state health department, hospital, or your doctor’s practice. fill this in first, then complete the official form.
03
who should i choose as my health care proxy?
someone who can be reached, who can stay steady in a hospital conversation, and who will represent your wishes rather than their own. proximity and calm matter more than closeness of relationship. always name a backup.
04
what should i tell my health care proxy?
what treatments you would want and would not want, what quality of life means to you, who else should be involved, and where your documents are kept. have the conversation out loud, not only on paper.
05
how often should i update it?
review it after any major change in your health, your relationships, or your wishes, and otherwise every year or two. an out-of-date proxy form naming someone unreachable is worse than none.
free to use, print and share. rox is a tracking tool, not medical advice, and it cannot diagnose or treat anything.