AB745,13,62 If I have checked “Yes" to the following, my health care agent may have a
3feeding tube withheld or withdrawn from me, unless my physician has advised that,
4in his or her professional judgment, this will cause me pain or will reduce my comfort.
5If I have checked “No" to the following, my health care agent may not have a feeding
6tube withheld or withdrawn from me.

AB745,13,97 My health care agent may not have orally ingested nutrition or hydration
8withheld or withdrawn from me unless provision of the nutrition or hydration is
9medically contraindicated.

AB745,13,1010 Withhold or withdraw a feeding tube — Yes.... No....

AB745,13,1211 If I have not checked either “Yes" or “No" immediately above, my health care
12agent may not have a feeding tube withdrawn from me.

AB745,13,1313 HEALTH CARE DECISIONS FOR

AB745,13,1414 PREGNANT WOMEN

AB745,13,1815 If I have checked “Yes" to the following, my health care agent may make health
16care decisions for me even if my agent knows I am pregnant. If I have checked “No"
17to the following, my health care agent may not make health care decisions for me if
18my health care agent knows I am pregnant.

AB745,13,1919 Health care decision if I am pregnant — Yes.... No....

AB745,13,2220 If I have not checked either “Yes" or “No" immediately above, my health care
21agent may not make health care decisions for me if my health care agent knows I am
22pregnant.

AB745,13,2323 STATEMENT OF DESIRES,

AB745,13,2424 SPECIAL PROVISIONS OR LIMITATIONS

AB745,14,4

1In exercising authority under this document, my health care agent shall act
2consistently with my following stated desires, if any, and is subject to any special
3provisions or limitations that I specify. The following are specific desires, provisions
4or limitations that I wish to state (add more items if needed):

AB745,14,88 INSPECTION AND DISCLOSURE OF

AB745,14,99 INFORMATION RELATING TO MY PHYSICAL

AB745,14,1010 OR MENTAL HEALTH

AB745,14,1211 Subject to any limitations in this document, my health care agent has the
12authority to do all of the following:

AB745,14,1413 (a) Request, review and receive any information, oral or written, regarding my
14physical or mental health, including medical and hospital records.

AB745,14,1615 (b) Execute on my behalf any documents that may be required in order to obtain
16this information.

AB745,14,1717 (c) Consent to the disclosure of this information.

AB745,14,1818 (The principal and the witnesses all must sign the document at the same time.)

AB745,14,1919 SIGNATURE OF PRINCIPAL

AB745,14,2020 (person creating the power of attorney for health care)

AB745,14,2121 Signature.... Date....

AB745,14,2322 (The signing of this document by the principal revokes all previous powers of
23attorney for health care documents.)