Patient Forms and Handouts
We have made it easy for you to keep track of your medications, by using this form:
Advanced Directive Forms:
Advance Directives are documents that explain to other your wishes related to your end-of-life care. They usually include the Health Care Power of Attorney form and the Living Will form. They may also include a mental health directive or other documents.
The Health Care Power of Attorney, also called a Medical Durable Power of Attorney, allows you to designate another person to represent you and your health care wishes. It would be used if you are in a situation where you are unable to make or communicate these decisions yourself.
The Living Will, also called a Declaration of a Desire for a Natural Death, is document stating that you do not want to have your life prolonged by extraordinary measures should you be in a vegetative state or have a terminal or incurable illness. The optional “Specific Medical Directives” allows you to clarify your specific wishes.
We recommend the following to help insure that your wishes are carried out:
Always initial or sign in places where you need to specify your wishes (do not use check marks).
Sign and date at the bottom of every page of every document.
Get all of your forms notarized! This is a requirement for the Living Will and the Health Care Power of Attorney.
Make sure the notary stamp is visible so it will show up when photocopied or scanned.
Give copies of all your Advance Directives to all of your health care providers, to every person named as a possible health care power of attorney, and to family members and/or close friends.
File your Advance Directives with the State of North Carolina Advance Health Care Directive Registry. For more information on this registry, go to: State of North Carolina Advance Heath Care Directive Registry.
Forms Depending on your Condition:
- Blood Sugar Log (Insulin) – English
- Blood Sugar Log (Insulin) – Spanish
- Blood Sugar Log (Non-Insulin) – English
- Blood Sugar Log (Non-Insulin) – Spanish
- Diabetes Eye Examination Results
- Guidelines for Checking Blood Sugar
- My Diabetes Self-Care Plan
- BRAT Diet Info
- Dash Booklet
- Gluten Free Diet
- Kidney Stone Diet
- Low Purine Diet
- Mediterranean Diet
- Portfolio Diet
- Blood Pressure Log
- BP Log – English
- BP Log – Spanish
- Hypertension Care Plan
- My Hypertension Self-Care Plan
- Your Guide to Lowering Your Blood Pressure with DASH
- Individual Care Plan for Smoking Cessation
- My Quit Smoking Self-Care Plan
- Resources for Smoking Cessation