華人社區預先醫療指示計劃問卷調查花一分鐘完成健康調查100美元!!! Take a survey about Advance Care Planning for a chance to win!

電話 / Phone Number *

(###)

###

####

您是否已經簽署正式的文件來指定您的醫療決策者？ / Have you SIGNED official papers naming a medical decision maker? *

您的醫療決策者是一位您的家庭成員或朋友，他/她將在您病重到無法自己作出醫療決定時為您作出醫療決定。/ A medical decision maker is a family member or friend who can make decisions for you if you were to become too sick to make your own decisions.

是 Yes

否 No

您是否已經和您的醫療決策者討論過，當您病重或接近生命盡頭時，您想接受怎樣的醫療護理？ / Have you TALKED to your medical decision maker about the kind of medical care you would want if you were very sick or near the end of life? *

是 Yes

否 No

您是否已經和您的醫生討論過，當您病重或接近生命盡頭時，您想接受怎樣的醫療護理？ / Have you TALKED to your doctor about the kind of medical care you would want if you were very sick or near the end of life? *

是 Yes

否 No

您是否簽署了正式的文件，以書面形式表達您在病重或接近生命盡頭時，您想接受醫療護理的意願？ / Have you SIGNED official papers putting your wishes in writing about the kind of medical care you would want if you were very sick or near the end of life? *

是 Yes

否 No

請問您多大年紀？ / What is your age? *

18歲以下 / Under 18

18 至 30 歲 / 18 - 30

31 至 50 歲 / 31 - 50

51 至 65 歲 / 51 - 65

66 至 80 歲 / 66 - 80

81 至 90 歲 / 81 - 90

90 歲以上 / Over 90

請問您在美國居住了多長時間？ / How many years have you lived in the US? *

少於 5 年 / Less than 5

5 至 10 年 / 5 - 10

10 至 20 年 / 10 - 20

20 年以上 / More than 20

您是否想讓我們聯繫您，幫您了解更多有關我們免費預先醫療指示計劃服務的信息？ / Would you like to get contacted to learn more about our free Advance Care Planning services? *

是 Yes

否 No