ADVANCE DIRECTIVE WORKSHEET
NAME_____________________________	HISTORY # _________________
Do you have an Advance Directive?	_____ YES     _____ NO
If Yes, Where is your Advance Directive located?	________________________________
If No, Do you wish to initiate an Advance Directive at this time?	_____ YES     _____ NO
Contact made to obtain existing Advance Directive	________________________________ Signature of Admissions Clerk
Patient contacted regarding Advance Directive by	________________________________ Admitting R.N.
Advance Directive received on Unit	________________________________ Date
IF PATIENT DETERMINES AFTER INITIAL CONTACT BY ADMITTING R.N. THAT DIRECTIVE IS NOT DESIRED AT THIS TIME, RECORD IN NURSING DOCUMENTATION.