My Care Wishes

Name :

Year of Birth :

This document reflects my values and care wishes, as of _____(date)_____. The values and care wishes indicate what is most important to me and I would like my Nominated Healthcare Spokesperson (NHS) to make health and personal care decisions on my behalf in future with these wishes in mind.

My Values

Q1. My favourite lifestyle / hobbies that give life meaning are:

  • fff

Reasons why I enjoy my lifestyle / hobbies:

  • fff

Q2. Activities that I do with my loved ones / others that give life meaning are:

  • fff

Reasons why I enjoy these activities:

  • fff

Q3. Beliefs I hold and religious activities I do that give life meaning are:

  • fff

Reasons why my religion and personal beliefs are important:

  • fff

My Well-being

Q4. How much I value my physical well-being in the following situations:

Very Important
Somewhat Important
Not Important

Q5. How much I value my mental well-being in the following situations:

Very Important
Somewhat Important
Not Important

Q6. How much I value my emotional well-being in the following situations:

Very Important
Somewhat Important
Not Important

My Care Wishes

Q7. My fears and worries about having a serious illness and about receiving medical care are:

Very Important
Somewhat Important
Not Important

Q8. If I am seriously ill and cannot speak, move around and make my own decisions one day...

  • fff

Q9. If I have an injury or illness, and my doctors believe that I would have a low chance of recovery...

  • fff

Q10. If I become very sick and nearing the end of life, these are the people or things I would like to have with me...

  • fff

Q11. Who I would want to be my Nominated Healthcare Spokesperson

  • fff