Myers and Porter, California Estate Planning Lawyer & Attorney - Probate, Wills, Trusts

3Back To Instructions

Values History Form

We hope this Values History Form is of help to you, your families and friends. Many people have commented that it is important to reflect not so much on "How I want to die," but rather on "How I want to LIVE until I die."

SECTION 1

A. WRITTEN LEGAL DOCUMENTS

Have you written any of the following legal documents? ________________________

If so, please complete the requested information.

Living Will

Date written: ______________________________________________________________

Document location: ________________________________________________________

Comments: (e.g., any limitations, special requests, etc.) ________________________

_________________________________________________________________________

Durable Power of Attorney

Date written: ______________________________________________________________

Document location: ________________________________________________________

Comments: (e.g., whom have you named to be your decision maker?)

_________________________________________________________________________

Durable Power of Attorney for Health Care Decisions

Date written: _____________________________________________________________

Document location: ________________________________________________________

Comments: (e.g., whom have you named to be your decision maker?)

_________________________________________________________________________

Organ Donations

Date written: ____________________________________________________________

Document location: _______________________________________________________

Comments: (e.g., any limitations on which organs you would like to donate?)

________________________________________________________________________

B. WISHES CONCERNING SPECIFIC MEDICAL PROCEDURES

If you have ever expressed your wishes, either written or orally, concerning any of the following medical procedures, please complete the requested information. If you have not previously indicated your wishes on these procedures and would like to do so now, please complete this information

Organ Donation

To whom expressed: ________________________________________________________

If oral, when? _______________________________________________________________

If written, when? ____________________________________________________________

Document location: __________________________________________________________

Comments: _________________________________________________________________

___________________________________________________________________________

Kidney Dialysis

To whom expressed: _________________________________________________________

If oral, when? _______________________________________________________________

If written, when? ____________________________________________________________

Document location: __________________________________________________________

Comments: ________________________________________________________________

___________________________________________________________________________

Cardiopulmonary Resuscitation (CPR)

To whom expressed: _______________________________________________________

If oral, when? ______________________________________________________________

If written, when? ___________________________________________________________

Document location: _________________________________________________________

Comments: _______________________________________________________________

__________________________________________________________________________

Respirators

To whom expressed: _______________________________________________________

If oral, when? _____________________________________________________________

If written, when? __________________________________________________________

Document location: ________________________________________________________

Comments: _______________________________________________________________

_________________________________________________________________________

Artificial Nutrition

To whom expressed: _______________________________________________________

If oral, when? _____________________________________________________________

If written, when? __________________________________________________________

Document location: ________________________________________________________

Comments: ______________________________________________________________

_________________________________________________________________________

Artificial Hydration

To whom expressed: _______________________________________________________

If oral, when? _____________________________________________________________

If written, when? __________________________________________________________

Document location: ________________________________________________________

Comments: _______________________________________________________________

_________________________________________________________________________

C. GENERAL COMMENTS

Do you wish to make any general comments about the information you provided in this section?

_________________________________________________________________________

SECTION 2

A. YOUR OVERALL ATTITUDE TOWARD YOUR HEALTH

1. How would you describe your current health status? If you currently have any medical problems, how would you describe them?

_________________________________________________________________________

2. If you have current medical problems, in what ways, if any, do they affect your ability to function?

_________________________________________________________________________

3. How do you feel about your current health status?

_________________________________________________________________________

4. How well are you able to meet the basic necessities of life‑‑eating, food preparation, sleeping, personal hygiene, etc.?

_________________________________________________________________________

5. Do you wish to make any general comments about your overall health?

_________________________________________________________________________

B. YOUR PERCEPTION OF THE ROLE OF YOUR DOCTOR AND OTHER HEALTH CAREGIVERS

1. Do you like your doctors?

_________________________________________________________________________

2. Do you trust your doctors?

_________________________________________________________________________

3. Do you think your doctors should make the final decision concerning any treatment you might need?

_________________________________________________________________________

4. How do you relate to your caregivers, including nurses, therapists, chaplains, social workers, etc.?

_________________________________________________________________________

5. Do you wish to make any general comments about your doctor and other health caregivers?

_________________________________________________________________________

C. YOUR THOUGHTS ABOUT INDEPENDENCE AND CONTROL

1. How important is independence and self‑sufficiency in your life?

_________________________________________________________________________

2. If you were to experience decreased physical and mental abilities, how would that
affect your attitude toward independence and self‑sufficiency?

_________________________________________________________________________

3. Do you wish to make any general comments about the value of independence and
control in your life?

_________________________________________________________________________

D. YOUR PERSONAL RELATIONSHIPS

1. Do you expect that your friends, family and/or others will support your decisions regarding
medical treatment you may need now or in the future?

_________________________________________________________________________

2. Have you made any arrangements for your family or friends to make medical treatment
decisions on your behalf? If so, who has agreed to make decisions for you and in what circumstances?

_________________________________________________________________________

3. What, if any, unfinished business from the past are you concerned about (e.g, personal and family relationships, business and legal matters)?

_________________________________________________________________________

4. What role do your friends and family play in your life?

_________________________________________________________________________

5. Do you wish to make any general comments about the personal relationships in your life?

_________________________________________________________________________

E. YOUR OVERALL ATTITUDE TOWARD LIFE

1. What activities do you enjoy (e.g., hobbies, watching TV, etc.)?

_________________________________________________________________________

2. Are you happy to be alive?

_________________________________________________________________________

3. Do you feel that life is worth living?

_________________________________________________________________________

4. How satisfied are you with what you have achieved in your life?

_________________________________________________________________________

5. What makes you laugh/cry?

_________________________________________________________________________

6. What do you fear most? What frightens or upsets you?

_________________________________________________________________________

7. What goals do you have for the future?

_________________________________________________________________________

8. Do you wish to make any general comments about your attitude toward life?

_________________________________________________________________________

F. YOUR ATTITUDE TOWARD ILLNESS, DYING, AND DEATH

1. What will be important to you when you are dying (e.g., physical comfort, no pain,
family members present, etc.)?

_________________________________________________________________________

2. Where would you prefer to die?

_________________________________________________________________________

3. What is your attitude toward death?

_________________________________________________________________________

4. How do you feel about the use of life-sustaining measures in the face of:

terminal illness? ____________________________________________________________

_________________________________________________________________________

permanent coma? _________________________________________________________

_________________________________________________________________________

irreversible chronic illness (e.g., Alzheimer's disease)? __________________________

_________________________________________________________________________

5. Do you wish to make any general comments about your attitude toward illness, dying, and death?

_________________________________________________________________________

G. YOUR RELIGIOUS BACKGROUND AND BELIEFS

1. What is your religious background?

_________________________________________________________________________

2. How do your religious beliefs affect your attitude toward serious or terminal illness?

_________________________________________________________________________

3. Does your attitude toward death find support in your religion?

_________________________________________________________________________

4. How does your faith community, church or synagogue view the role of prayer or religious
sacraments in an illness?

_________________________________________________________________________

5. Do you wish to make any general comments about your religious background and beliefs?

_________________________________________________________________________

H. YOUR LIVING ENVIRONMENT

1. What has been your living situation over the last 10 years (e.g., lived alone, lived with others, etc.)?

_________________________________________________________________________

_________________________________________________________________________

2. How difficult is it for you to maintain the kind of environment for yourself that you find comfortable?
Does any illness or medical problem you have now mean that it will be harder in the future?

_________________________________________________________________________

3. Do you wish to make any general comments about your living environment?

_________________________________________________________________________

I. YOUR ATTITUDE CONCERNING FINANCES

1. How much do you worry about having enough money to provide for your care?

_________________________________________________________________________

2. Would you prefer to spend less money on your care so that more money can be saved for
the benefit of your relatives and/or friends?

_________________________________________________________________________

3. Do you wish to make any general comments concerning your finances and the cost of health care?

_________________________________________________________________________

J. YOUR WISHES CONCERNING YOUR FUNERAL

1. What are your wishes concerning your funeral and burial or cremation?

_________________________________________________________________________

2. Have you made your funeral arrangements? If so, with whom?

_________________________________________________________________________

3. Do you wish to make any general comments about how you would like your funeral
and burial or cremation to be arranged or conducted?

_________________________________________________________________________

OPTIONAL QUESTIONS

1. How would you like your obituary (announcement of your death) to read?

_________________________________________________________________________

2. Write yourself a brief eulogy (a statement about yourself to be read at your funeral).

_________________________________________________________________________

SUGGESTIONS FOR USE:

After you have completed this form, you may wish to provide copies to your doctors and other caregivers, your family, your friends, and your attorney. If you have a Living Will or Durable Power of Attorney for Health Care Decisions, you may wish to attach a copy of this form to those documents.

[Form 3.203--Values History Form]