End-of-Life Preferences Questionnaire

Personal Information

Full Name Date of Birth

Healthcare Preferences

Level of Medical Intervention

Full Intervention Limited Intervention Comfort Care Only

Advance Directives (Living Will, DNR, etc.)

Decision Maker

Appointed Healthcare Proxy or Decision Maker Contact Information

Spiritual & Emotional Preferences

Spiritual or Religious Beliefs Emotional Support Persons

Other Wishes

Special Instructions or Final Wishes