1 An indication of whether the practitioner consulted with other health care professionals — other than a practitioner who received the patient’s written request for medical assistance in dying as described in section 3 of these Regulations — or social workers in order to determine whether the patient met the eligibility criteria and, if so, the professions of those persons.
2 An indication of which of the following eligibility criteria were assessed by the practitioner and whether the practitioner was of the opinion that the patient met or did not meet each of those criteria:
(a) the patient was eligible — or, but for any applicable minimum period of residence or waiting period, would have been eligible — for health services funded by a government in Canada;
(b) the patient was at least 18 years of age;
(c) the patient was capable of making decisions with respect to their health;
(d) the patient made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure and, if the practitioner assessed this criterion and was of the opinion that the patient met it, the reasons why the practitioner was of that opinion;
(e) the patient gave informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care;
(f) the patient had a serious and incurable illness, disease or disability and, if the practitioner assessed this criterion and was of the opinion that the patient met it, a description of the illness, disease or disability;
(g) the patient was in an advanced state of irreversible decline in capability;
(h) the illness, disease or disability or state of decline caused the patient enduring physical or psychological suffering that was intolerable to them and that could not be relieved under conditions that they considered acceptable and, if the practitioner assessed this criterion and was of the opinion that the patient met it, the patient’s description of the suffering;
(i) the patient’s natural death had become reasonably foreseeable, taking into account all of their medical circumstances.
3 An indication of whether the patient received palliative care, if known, and
4 An indication of whether the patient required disability support services, if known, and if so,
(a) if the patient received disability support services, how long the patient received those services, if known; or
(b) if the patient did not receive disability support services, an indication of whether, to the best of the practitioner’s knowledge or belief, disability support services were accessible to the patient.
5 In the case where the practitioner determined that the patient met all of the eligibility criteria but subsequently determines that the patient does not meet one or more of those criteria, an indication of
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