Guardianship and Administration Amendment Regulations 2022 (WA)

No judgment structure available for this case.

17 June 2022 GOVERNMENT GAZETTE, WA 3405
JU302
Guardianship and Administration Act 1990

Guardianship and Administration Amendment
Regulations 2022

SL 2022/102

Made by the Governor in Executive Council.
1. Citation

These regulations are the Guardianship and Administration
Amendment Regulations 2022.
2. Commencement
These regulations come into operation as follows

(a) regulations 1 and 2 on the day on which these
regulations are published in the Gazette;

(b) the rest of the regulations on 4 August 2022.
3. Regulations amended

These regulations amend the Guardianship and Administration
Regulations 2005.
4. Part 4 inserted
After regulation 8 insert:
Part 4 - Transitional provisions for

Guardianship and Administration Amendment
Regulations 2022

9. Advance health directive form during transitional
period

(1) In this regulation
commencement day means 4 August 2022;
former regulations means these regulations as in force
immediately before commencement day;
transitional period means the period of 6 months
beginning on commencement day.
(2) During the transitional period, each of the following is
the form prescribed for an advance health directive

(a) the form in Schedule 2;

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(b) the form in Schedule 2 of the former
regulations.
5. Schedule 2 replaced
Delete Schedule 2 and insert:
Schedule 2 Advance health directive form

[r. 7]

ADVANCE HEALTH DIRECTIVE FORM

This form is for people who want to make an Advance Health
Directive in Western Australia.
To make an Advance Health Directive, you must be 18 years or older and have full legal capacity. Your Advance Health Directive is about your future treatment. It will only come into effect if you are unable to make reasonable judgments or decisions at a time when you require treatment.

4 Part 4, marked with this symbol, contains your treatment decisions. If
you choose not to make any treatment decisions in Part 4, then the
document is not considered a valid Advance Health Directive under
the Guardianship and Administration Act 1990.
Please tick the box below to indicate that by making this Advance completed
by you.
LI In making this Advance Health Directive, I revoke all prior Advance
Health Directives made by me.

examples, please read A Guide to Making an Advance Health Directive in
This form includes instructions to help you complete your Advance Health

Western Australia.
Before you make your Advance Health Directive, you are encouraged to
seek legal and/or medical advice, and to discuss your decisions with
family and close friends. It is important that people close to you know that
you have made an Advance Health Directive and where to find it. Once
you complete your Advance Health Directive, it is recommended that you:

• store the original in a safe and accessible place and tell your close family and friends that you have made an Advance Health Directive and where to find it

17 June 2022 GOVERNMENT GAZETTE, WA 3407

• upload a copy of your Advance Health Directive to your My Health Record this will ensure that your Advance Health Directive is available to your treating doctors if it is needed
• give a copy of your Advance Health Directive to health professionals regularly involved in your health care (for example, your General Practitioner (GP), a hospital you attend regularly, and/or other health professionals involved in your care).
This form must be completed in English. If English is not your first language, you may need help to understand and complete this form. Contact the National Accreditation Authority for Translators and
Interpreters for help.
PART 1: MY PERSONAL DETAILS
You must complete this part

You must complete This Advance Health Directive is made under
Part 1. the Guardianship and Administration Act 1990

Part 9B on the of
You must include the

('y) (month) (year)

date, your full name,
date of birth and by

address. (name)
Full name
Date of birth
Address
WA

(suburb) (postcode)

Phone number
Email

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17 June 2022

PART 2: MY HEALTH

2. 1 My major health conditions

Use Part 2.1 to list Please list any major health conditions below:
details about your
major health
conditions (physical
and/or mental).
Cross out Part 2.1 if
you do not want to
complete it.

2. 2 When talking with me about my health, these things are
important to me

Use Part 2.2 to Please describe what is important to you when
provide information talking to health professionals about your
about what is treatment:
important to you
when talking about
your treatment.
This might include:

• How much you like to know about your health conditions
• What you need to
help you make
decisions about
treatment
• Whether you like to have certain family members with you when receiving

information from
your health
professionals
Cross out Part 2.2 if
you do not want to
complete it.

PART 3: MY VALUES AND PREFERENCES

This part encourages you to think about your values and preferences relating to your health and care now and into the future. This may help you to decide what treatment decisions you want to make in Part 4: My Advance Health Directive Treatment Decisions.
In this part, you are not making decisions about your future treatment. Use
Part 4 to make decisions about your future treatment.
Cross out any parts that you do not want to complete.

17 June 2022 GOVERNMENT GAZETTE, WA 3409

3. 1 These things are important to me

Use Part 3.1 to Please describe what "living well" means to you
provide information now and into the future. Use the space below
about what "living and/or tick which boxes are important for you.
well" means to you
now and into the Please describe:
future.
This might include:

• What the most
important things in
your life are

LI Spending time with family and friends

• What "living well"

means to you LILiving independently

LI Being able to visit my home town, country of
Cross out Part 3.1 if

you do not want to origin, or spending time on country

complete it. 11 Being able to care for myself (e.g. showering,
going to the toilet, feeding myself)
11 Keeping active (e.g. playing sport, walking,
swimming, gardening)
11 Enjoying recreational activities, hobbies and
interests (e.g. music, travel, volunteering)

LI

Practising religious, cultural, spiritual and/or community activities (e.g. prayer, attending religious services)
LI Living according to my cultural and religious
values (e.g. eating halal, kosher foods only)
11 Working in a paid or unpaid job
3.2 These are things that worry me when I think about my future
health

Use Part 3.2 to Please describe any worries you have about the
provide information outcomes of future illness or injury:
about things that
worry you about your
future health.
This might include:

• Being in constant
pain
• Not being able to
make your own
decisions
• Not being able to care for yourself
Cross out Part 3.2 if
you do not want to
complete it.

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17 June 2022

3.3 When I am nearing death, this is where I would like to be

Use Part 3.3 to Please indicate where you would like to be when
indicate where you you are nearing death. Tick the option that
would like to be when applies to you. You can provide more detail
you are nearing about the option you choose in the space below.
death.

L I want to be at home where I am living at
When you are nearing

death, do you have a the time

preference of where L1 I do not want to be at home provide more

you would like to details below
spend your last days or

weeks? Li I do not have a preference I would like to be
wherever I can receive the best care for my

Cross out Part 3.3 if needs at the time
you do not want to

complete it. Li Other please specify:
Please provide more detail about your choice:

3.4 When I am nearing death, these things are important to me

Use Part 3.4 to Please describe what is important to you and
provide information what would comfort you when you are nearing
about what is death. Use the space below and/or tick which
important to you boxes are important for you.
when you are nearing
death. Please describe:
This might include:

• What would comfort
you when you are
dying Li I do not want to be in pain, I want my
• Who you would like

around you symptoms managed, and I want to be as
comfortable as possible

Cross out Part 3.4 if (Please provide details of what being
you do not want to comfortable means to you)
complete it.

Li I want to have my loved ones and/or pets
around me
(Please provide details of who you would like
with you)
It is important to me that cultural or religious
traditions are followed
(Please provide details of any specific
traditions that are important for you)

17 June 2022 GOVERNMENT GAZETTE, WA 3411
I want to have access to pastoral/spiritual care
(Please provide details of what is important for
you)

Li My surroundings are important to me (e.g.
quiet, music, photographs)
(Please provide details of what is important for
you)
PART 4: MY ADVANCE HEALTH DIRECTIVE

TREATMENT DECISIONS 4

This part of your Advance Health Directive contains treatment decisions
in respect of your future treatment. A treatment is any medical or surgical
treatment (including palliative care or life-sustaining measures such as
assisted ventilation and cardiopulmonary resuscitation), dental treatment,
or other health care.
A treatment decision in an Advance Health Directive is a decision to consent or refuse consent to the commencement or continuation of any treatment and includes a decision to consent or refuse consent to the
commencement or continuation of the person's participation in medical
research. This decision applies at any time you are unable to make
reasonable judgments in respect of that treatment.
Treatment you consent to in this Advance Health Directive can be provided to you. Treatment you refuse consent to in this Advance Health Directive cannot be provided to you. Your enduring guardian or guardian or another person cannot consent or refuse consent on your behalf to any treatment to which this Advance Health Directive applies.
It is recommended that you discuss your treatment decisions with your doctor before completing this part.

Cross out any parts that you do not want to complete.
You MUST make at least one treatment decision in Part 4 to make a valid Advance Health Directive.

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4.1 Life-sustaining treatment decisions 4

Use Part 4.1 to If I do not have the capacity to make or
indicate your communicate treatment decisions about my
instructions for future health care in the future, I make the following
life-sustaining decisions about life-sustaining treatment:
treatments.
(Tick only one of the following options. If you
You can give an overall choose Option 4, complete the table overleaf).
instruction or list
individual treatments

Option 1 11 I consent to all treatments aimed at

that you consent or sustaining or prolonging my life.
refuse consent to
receiving in the future.

You can also list OR
circumstances in which

Option 2 11 I consent to all treatments aimed at
you consent or refuse

consent to a particular sustaining or prolonging my life

treatment,

unless it is apparent that I am so unwell from injury or illness that
Life-sustaining there is no reasonable prospect that
treatments are I will recover to the extent that I
treatments used to keep can survive without continuous
you alive or to delay life-sustaining treatments. In such a
your death, situation, I withdraw consent to
life-sustaining treatments.

Read all options before making a decision. The options are over two

OR
pages.

Option 3 11 I refuse consent to all treatments

Cross out Part 4.1 if aimed at sustaining or prolonging
you do not want to my life.
complete it.

You MUST make at OR
least one treatment
decision in Part 4 to

Option 4 Li I make the following decisions

make a valid Advance about specific life-sustaining
Health Directive, treatments as listed in the table
below.
(Tick a box in each row of the

table)
OR

Option 5 El I cannot decide at this time

Please complete this table if you have ticked Option 4 above.
If you have ticked Option 1, 2, 3 or 5, do not complete this table.
This table lists some common life-sustaining treatments. Use the boxes to indicate which treatments you consent or refuse consent to receiving. You can also list circumstances in which you consent to treatment. There is
also space for you to add any life-sustaining treatments not listed here.
Tick one box per row in the table below.
If you choose Option B for any treatments, please specify the circumstances in which you consent to the treatment.

17 June 2022 GOVERNMENT GAZETTE, WA 3413

Life-sustaining A. B. C. D.
treatment

I consent to I consent to this I refuse consent I cannot

this treatment treatment in the to this decide at

in all following treatment in all this time

circumstances circumstances circumstances

CPR L1 L1 L1 Ll

Cardiopulmonary In which circumstances do
resuscitation you consent to this treatment?
Assisted
ventilation
In which circumstances do
A machine that you consent to this treatment?
helps you breathe
using a face
mask or tube

Artificial L1 L1 L1 Ll
hydration
In which circumstances do

Fluids given via you consent to this treatment?
a tube into a
vein, tissues or
the stomach

Artificial nutrition

L1

L1

L1

11
In which circumstances do

A feeding tube you consent to this treatment?
through the nose
or stomach

Receiving blood
products such L1 L1 L1 Ll

as a blood In which circumstances do
transfusion you consent to this treatment?

Antibiotics

Drugs that are In which circumstances do
used to treat you consent to this treatment?
infection
Use the boxes below to list any other life-sustaining treatments you do/do not consent to receive:

Other P1

life-sustaining treatment (1)

In which circumstances do
you consent to this treatment?
State the
treatment:

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17 June 2022

Other Ll 1
life-sustaining

treatment (2) In which circumstances do
you consent to this treatment?
State the
treatment:

4.2 Other treatment decisions 4

Use Part 4.2 to Health circumstances My treatment decisions
indicate your
decisions for other
(non-life-sustaining)
treatments.

There are a range of other treatments that may be options for you
in the future.
Examples include
treatments for mental
health (e.g.
electroconvulsive
therapy) and drugs
used to prevent certain
health conditions (e.g.
aspirin, cholesterol
treatments).
When making a
treatment decision, list
the circumstances in
which you want your
decision to apply (e.g.
in all circumstances, or
specify particular
circumstances).

A treatment decision
only applies in the
circumstances you
specify.
Please ensure that you
indicate in the "My
treatment decisions"
column whether you
consent or refuse
consent to any
treatment you refer to.
If you need more

space, use the template Li I have made more treatment decisions using
in the Guide to Making

the template and attached (spec?Jj.'
an Advance Health number ofpages) additional pages.
Directive in Western
Australia and attach it
to your Advance
Health Directive form.

17 June 2022 GOVERNMENT GAZETTE, WA 3415
Cross out Part 4.2 if
you do not want to
complete it.
You MUST make at least one treatment decision in Part 4 to make a valid Advance
Health Directive.

4.3 Medical research 4

Use Part 4.3 to provide treatment decisions about the medical research activities you consent or refuse consent to take part in, and any circumstances in which these decisions apply.

Taking part in medical research may be an option for you even if you are unable to make or communicate decisions.

A treatment decision may include deciding whether to start or continue to take part in medical research. Your involvement in medical research, and any treatments you receive as part of the medical research, must be

consistent with what you have agreed in your Advance Health Directive. participating in medical research only operate while you are alive.

If you do not make a decision about participation in medical research, to how decisions will be made about participation in medical research.
Cross out Part 4.3 if you do not want to complete it.

You MUST make at least one treatment decision in Part 4 to make a valid Advance Health Directive.

Please tick a box showing whether you consent to taking part in the listed medical research activities and the circumstances in which you consent. You may lick more than one circumstance for each research

activity.

I consent to taking part in the following circumstances:

I do not consent

Where I Where the Where the Where there
require medical medical are no other
urgent research may research may treatment
treatment to improve my not improve options
save my life, condition or my condition
or to prevent illness or illness but

RESEARCH serious may lead to a
ACTIVITIES damage to better
my health, or understanding
to prevent of my
me suffering condition or
or continuing illness in the
to suffer future
significant
pain and
distress

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The
administration

of LI El LI LI LI
pharmaceuticals
or placebos
(inactive drug)
The use of
equipment or a LI LI L] LI L]
device
Providing
health care that
has not yet gained the support ofa
substantial LI El 11 El 11
number of
practitioners in
that field of
health care
Providing
health care to
carry out a LI LI LI LI LI
comparative assessment
Taking blood
samples LI El 11 El 11
Taking samples
of tissue or
fluid from the
body, including LI El LI El LI
the mouth,
throat, nasal
cavity, eyes or
ears
Any
non-intrusive
examination of

the mouth, LI LI LI LI LI
throat, nasal
cavity, eyes or
ears

A non-intrusive examination of

LI

El

11

F-I

11
height, weight
or vision
Observing an
individual LI LI LI LI LI
Undertaking a
survey, LI LI LI LI LI

interview or focus group

17 June 2022 GOVERNMENT GAZETTE, WA 3417
Collecting,
using or
disclosing

information, El El L] El L]

including personal information
Considering or
evaluating
samples or
information El El LI LI LI

taken under an activity listed above
Any other
medical Ll El El El LI

research not listed above
PART 5: PEOPLE WHO HELPED ME COMPLETE THIS FORM

5. 1 Did an interpreter help you to complete this form?

Use Part 5.1 to show Tick the option that applies to you:
whether an
interpreter helped

Option 1 Ll English is my first language I did

you to complete this not need to use an interpreter
form.

If English is not your Option 2 Li English is NOT my first language
first language, you can an interpreter helped me make this
use an interpreter to Advance Health Directive and I have
help you complete this attached an interpreter statement
form.
Option 3 Li English is NOT my first language
If you use an
interpreter to help you I did NOT receive help from an
to complete this interpreter to make this Advance

Advance Health Health Directive
Directive, you and your
interpreter should
complete the
interpreter statement
provided in A Guide to
Making an Advance
Health Directive in
Western Australia and
attach it to your
Advance Health
Directive.
Cross out Part 5.1 if
you do not want to
complete it.

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5. 2 Have you made an Enduring Power of Guardianship (EPG)?

Use Part 5.2 to indicate Tick the option that applies to you:
whether you have made
an Enduring Power of

Option 1 Li I have NOT made an Enduring Power

Guardianship (EPG) of Guardianship
and provide details if

relevant. Option 2 Li I have made an Enduring Power of

An Enduring Power of Guardianship

Guardianship allows
you to name and
legally appoint one or My EPG was made on:
more people to make

decisions about your (y) (month) (year)

lifestyle and health care My EPG is kept in the following place (be as specific
if you lose capacity. as possible):

A person you appoint to make decisions on your behalf is called an

I appointed the following person/s as my
enduring guardian. enduring guardian.
An enduring guardian

Name Phone
cannot override
decisions made in your Joint enduring guardian (if appointed):
Advance Health

Name Phone
Directive.
Cross out Part 5.2 if Substitute enduring guardian (if any):
you do not want to

Name Phone
complete it.

Other substitute enduring guardian (if more than one):

Name Phone

5.3 Did you seek medical and/or legal advice about making this
Advance Health Directive?

Use Part 5.3 to Medical Advice - tick the option that applies to
indicate whether you you

obtained medical
and/or legal advice Option 1 Li I did NOT obtain medical advice

before making this about the making of this Advance
Advance Health Health Directive.

Directive and provide
details if relevant. Option 2 Li I DID obtain medical advice about

You are encouraged the making of this Advance Health
(but not required) to Directive.
seek medical or legal
advice to make an I obtained medical advice from:
Advance Health Name
Directive.
Phone
Cross out Part 5.3 if
you do not want to Practice
complete it.
Legal Advice - tick the option that applies to you

17 June 2022 GOVERNMENT GAZETTE, WA 3419

Option 1 Li I did NOT obtain legal advice
about the making of this Advance
Health Directive.

Option 2 Li I DID obtain legal advice about the
making of this Advance Health
Directive.
I obtained legal advice from:
Name
Phone
Practice
PART 6: SIGNATURE AND WITNESSING
You must complete this Part

• You must sign this Advance Health Directive in the presence of two (2) witnesses. If you are physically incapable of signing this Advance Health Directive, you can ask another person to sign for you.
You must be present when the person signs for you.

• Two (2) witnesses must be present when you sign this Advance Health Directive or when another person signs for you.
• Each of the witnesses must be 18 years of age or older and cannot be you or the person signing for you (if applicable).
• At least one of the witnesses must be authorised by law to take statutory declarations.
• The witnesses must also sign this Advance Health Directive. Both witnesses must be present when each of them signs. You and the person signing for you (if applicable) must also be present when the witnesses sign.

• If you need to use a marksman clause to sign this Advance Health Directive, you should complete the marksman clause template provided in A Guide to Making an Advance Health Directive in Western Australia and attach it to your Advance Health Directive.
YOU MUST SIGN THIS FORM IN THE PRESENCE OF TWO (2) WITNESSES. BOTH WITNESSES MUST BE PRESENT WHEN
YOU SIGN THIS FORM. THE WITNESSES MUST SIGN IN EACH

OTHER'S PRESENCE.

Signed by:
(signature ofperson making this Advance Health Directive)

Date: I I
(day) (month) (year)

OR

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Signed by:
(insert name of person who the maker of Advance Health Directive
has directed to sign)
in the presence of, and at the direction of
(insert name of maker of Advance Health Directive)

Date: / /
(day) (month) (year)

Witnessed by a person authorised by law to take statutory declarations:
Authorised witness's signature
Authorised witness's full name
Address
Occupation of authorised
witness

Date / /

(day) (month) (year)

And witnessed by another person:
Witness's signature
Witness's full name
Address

Date / /

(day) (month) (year)

V. MOLAN, Clerk of the Executive Council.

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Citations

Guardianship and Administration Amendment Regulations 2022 (WA)

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9.	Advance health directive form during transitional period
(1)	In this regulation *commencement day* means 4 August 2022; *former regulations* means these regulations as in force immediately before commencement day; *transitional period* means the period of 6 months beginning on commencement day.
(2)	During the transitional period, each of the following is the form prescribed for an advance health directive

•	upload a copy of your Advance Health Directive to your My Health Record this will ensure that your Advance Health Directive is available to your treating doctors if it is needed
•	give a copy of your Advance Health Directive to health professionals regularly involved in your health care (for example, your General Practitioner (GP), a hospital you attend regularly, and/or other health professionals involved in your care).

date, your full name, date of birth and	by
address.	(name)
Full name
Date of birth
Address

Use Part 2.1 to list	Please list any major health conditions below:
details about your major health conditions (physical and/or mental).
Cross out Part 2.1 if you do not want to complete it.

Use Part 3.1 to	Please describe what "living well" means to you
provide information	now and into the future. Use the space below
about what "living	and/or tick which boxes are important for you.
well" means to you
now and into the	Please describe:
future.
This might include:
•	What the most important things in your life are

complete it.	11	Being able to care for myself (e.g. showering, going to the toilet, feeding myself)
11	Keeping active (e.g. playing sport, walking, swimming, gardening)
11	Enjoying recreational activities, hobbies and interests (e.g. music, travel, volunteering)
LI	Practising religious, cultural, spiritual and/or community activities (e.g. prayer, attending religious services)
LI	Living according to my cultural and religious values (e.g. eating halal, kosher foods only)
11	Working in a paid or unpaid job

Use Part 3.2 to	Please describe any worries you have about the
provide information	outcomes of future illness or injury:
about things that worry you about your future health.
This might include:
•	Being in constant pain
•	Not being able to make your own decisions
•	Not being able to care for yourself

Cross out Part 3.3 if	needs at the time
you do not want to

Use Part 3.4 to	Please describe what is important to you and
provide information	what would comfort you when you are nearing
about what is	death. Use the space below and/or tick which
important to you	boxes are important for you.
when you are nearing
death.	Please describe:
This might include:

around you	symptoms managed, and I want to be as
comfortable as possible
Cross out Part 3.4 if	(Please provide details of what being
you do not want to	comfortable means to you)
complete it.

Li	I want to have my loved ones and/or pets around me (Please provide details of who you would like with you)
It is important to me that cultural or religious traditions are followed (Please provide details of any specific traditions that are important for you)

I consent to	I consent to this	I refuse consent	I cannot
this treatment	treatment in the	to this	decide at

Cardiopulmonary	In which circumstances do
resuscitation	you consent to this treatment?
Assisted ventilation
In which circumstances do
A machine that	you consent to this treatment?
helps you breathe using a face mask or tube

Fluids given via	you consent to this treatment?
a tube into a vein, tissues or the stomach

A feeding tube	you consent to this treatment?
through the nose or stomach

as a blood	In which circumstances do
transfusion	you consent to this treatment?
Antibiotics
Drugs that are	In which circumstances do
used to treat	you consent to this treatment?
infection

Other	P1
life-sustaining treatment (1)	In which circumstances do
you consent to this treatment?
State the treatment:

treatment (2)	In which circumstances do
you consent to this treatment?
State the treatment:

4.2	Other treatment decisions	4
Use Part 4.2 to	Health circumstances	My treatment decisions
indicate your decisions for other (non-life-sustaining) treatments.
There are a range of other treatments that may be options for you
in the future.
Examples include treatments for mental health (e.g. electroconvulsive therapy) and drugs used to prevent certain health conditions (e.g. aspirin, cholesterol treatments).
When making a treatment decision, list the circumstances in which you want your decision to apply (e.g. in all circumstances, or specify particular circumstances).

4.3 Medical research	4
Use Part 4.3 to provide treatment decisions about the medical research activities you consent or refuse consent to take part in, and any circumstances in which these decisions apply.
Taking part in medical research may be an option for you even if you are unable to make or communicate decisions.
A treatment decision may include deciding whether to start or continue to take part in medical research. Your involvement in medical research, and any treatments you receive as part of the medical research, must be
consistent with what you have agreed in your Advance Health Directive. participating in medical research only operate while you are alive.
If you do not make a decision about participation in medical research, to how decisions will be made about participation in medical research.
Cross out Part 4.3 if you do not want to complete it.
You MUST make at least one treatment decision in Part 4 to make a valid Advance Health Directive.
Please tick a box showing whether you consent to taking part in the listed medical research activities and the circumstances in which you consent. You may lick more than one circumstance for each research

Where I	Where the	Where the	Where there
require	medical	medical	are no other
urgent	research may	research may	treatment
treatment to	improve my	not improve	options
save my life,	condition or	my condition
or to prevent	illness	or illness but

RESEARCH	serious	may lead to a
ACTIVITIES	damage to	better
my health, or	understanding
to prevent	of my
me suffering	condition or
or continuing	illness in the
to suffer	future
significant pain and distress

of	LI	El	LI	LI	LI
pharmaceuticals or placebos (inactive drug)
The use of
equipment or a	LI	LI	L]	LI	L]
device
Providing
health care that
has not yet gained the support ofa
substantial	LI	El	11	El	11
number of practitioners in that field of health care
Providing
health care to
carry out a	LI	LI	LI	LI	LI
comparative assessment
Taking blood
samples	LI	El	11	El	11
Taking samples of tissue or fluid from the body, including	LI	El	LI	El	LI
the mouth, throat, nasal cavity, eyes or ears
Any
non-intrusive
examination of

the mouth,	LI	LI	LI	LI	LI
throat, nasal cavity, eyes or ears
A non-intrusive examination of	LI	El	11	F-I	11
height, weight or vision
Observing an
individual	LI	LI	LI	LI	LI
Undertaking a survey,	LI	LI	LI	LI	LI
interview or focus group

information,	El	El	L]	El	L]
including personal information
Considering or
evaluating
samples or
information	El	El	LI	LI	LI
taken under an activity listed above
Any other medical	Ll	El	El	El	LI
research not listed above

If English is not your	Option 2	Li	English is NOT my first language
first language, you can	an interpreter helped me make this
use an interpreter to	Advance Health Directive and I have
help you complete this	attached an interpreter statement
form.
Option 3	Li	English is NOT my first language
If you use an
interpreter to help you	I did NOT receive help from an
to complete this	interpreter to make this Advance

Use Part 5.3 to	Medical Advice -	tick the option that applies to
indicate whether you	you
obtained medical and/or legal advice	Option 1	Li I did NOT obtain medical advice

before making this	about the making of this Advance
Advance Health	Health Directive.

You are encouraged	the making of this Advance Health
(but not required) to	Directive.
seek medical or legal
advice to make an	I obtained medical advice from:
Advance Health	Name
Directive.
Phone
Cross out Part 5.3 if
you do not want to	Practice
complete it.

•	Two (2) witnesses must be present when you sign this Advance Health Directive or when another person signs for you.
•	Each of the witnesses must be 18 years of age or older and cannot be you or the person signing for you (if applicable).
•	At least one of the witnesses must be authorised by law to take statutory declarations.
•	The witnesses must also sign this Advance Health Directive. Both witnesses must be present when each of them signs. You and the person signing for you (if applicable) must also be present when the witnesses sign.