1. This program will write a LIVING WILL for you. This is a notice to your doctor(s) that you do not wish life-sustaining procedures used to continue your life if your death is imminent.  
2. What is your name?
3. Are you male?
4. What City or Town do you live in?
5. Do you live in a County or Parish?
6. Please enter the name of the County or Parish.
7. Please enter the name of the State or Territory where you live.
8. Please enter the day of the month.  (This should be a number and suffix such as "1st", "2nd" or "3rd".)
9. Please enter the month this document is to be signed.
10. Please enter the year that this document will be signed.
11. Do you wish to insist that two physicians have made a determination as to the likelihood of your death? (Answering "yes" here will allow for two physicians, whereas answering "no" will allow for one.)
12. Do you wish that this directive will not be effective if you are pregnant?
13. Have you been diagnosed as having a terminal condition?  (This diagnosis should be at least 14 days prior to signing this document.)
14. Who made the diagnosis?
15. What is the address of [14]?
16. Do you wish to include the phone number of [14]?
17. What is the phone number?
18. Do you wish to have this document terminate after a certain number of years from the date of execution?
19. In how many years do you wish this document to terminate?
20. This document needs to be witnessed by two persons.  Do you know the names of the persons who will witness this document?
21. What is the name of the first witness?
22. What is the name of the second witness?
23. You are now done with the questions.  The program will now create a "Living Will" for you specifically as you have defined it.