VAD - APPLICATION AND BIOGRAPHY

First name(s)

Last name

Date of Birtth

Tag

Monat

Jahr

Day Month Year

E-Mail

Phone

Nationality

Address

Postal Code

City

Country

I use WhatsApp

I use Telegram

I use Signal

Occupation (before retirement)

Reason for applying for a VAD

Family of origin & Childhood

School & Education

Employment & Career

Current marital status: married, divorced, widowed or single?

Do you have children?

Are your relatives informed (spouse, parents, children, siblings)?

Leisure time, hobbies, voluntary work

Do you have any pets?

Diagnose(s)

Current treatment regimen

Current medications

Have you ever been diagnosed with a mental illness?

Yes

If yes, which?

Have you ever been diagnosed with a neurological disorder?

Yes

If yes, which?

Accompanying person(s)

If you are already a member of a euthanasia organization, please let us know which organization(s)

Further information

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