Do you have a living will?*

Yes
No

Do you have a medical power of attorney?*

Yes
No

Do you know the amount, if any, of your health insurance annual deductible (the amount you have to pay towards health related expenses before your insurance kicks in)?*

Yes
No

Do you know the amount, if any, of your insurance copayment (coinsurance)?*

Yes
No

Do you know your health insurance policy's out-of-pocket annual maximum?*

Yes
No

Does your insurance plan limit you to a particular network of doctors?*

Yes
No

When you get a bill from your health provider, do you know the difference between the charged amount and the allowable amount?*

Yes
No

If you take any prescribed medications, do you know what each medicine is for and what it's supposed to do?*

Yes
No

Do you keep a list of all your medications and supplements, with dosages?*

Yes
No

Do you keep a list of any medication allergies?*

Yes
No

Are you up to date with routine cancer screenings? Answer 12-14

Pap Smear?*

Yes
No

Mammogram?*

Yes
No

Colonoscopy?*

Yes
No

Do you know the cancer history of your family members, including type of cancer and age at diagnosis?*

Yes
No

Has your doctor reviewed your family history and discussed potential hereditary health risks with you?*

Yes
No

Have you taken a hereditary cancer risk quiz such as Myriad's at hereditarycancerquiz.com?*

Yes
No

Are your doctors board certified in their respective specialties?*

Yes
No

Do you know the difference between a pathology report and an operative report?*

Yes
No

Do you have copies of your pathology and operative reports from any surgical procedures you have had?*

Yes
No

Does your surgeon perform minimally invasive surgery?*

Yes
No

Assessment

Are You an Empowered Patient?