Values Worksheet - Medical Questionnaire Form printable pdf download

Values Worksheet - Medical Questionnaire Form

Values Worksheet

Being aware of our own values is crucial when considering what is most important at the end of

one’s life. The following questions you may want to consider as you make decisions and prepare

documents concerning your healthcare preferences.

Not

Desirable

Important

Essential

Necessary

Avoiding expensive care

Being able to leave money to family friends

or charity

Being able to relate to family and friends

Being comfortable and as pain free as

possible

Being free of physical limitations

Being independent

Being mentally alert and competent

Dying in a short while rather than lingering

Leaving good memories for my family and

friends

Letting nature takes its course

Living as long as possible regardless of

quality of life

Making a contribution to medical research

or teaching

Preserving quality of life

Staying true to my spiritual beliefs and

traditions

That death occurs during sleep

Dying naturally without technical equipment

That loved ones be present

That the ability to communicate be present

until death

Having a chance to complete important

tasks

Having an opportunity to say goodbye

Being able to accept death

Remain at home

Values Worksheet - Medical Questionnaire Form