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.
Q1. My favourite lifestyle / hobbies that give life meaning are:
Reasons why I enjoy my lifestyle / hobbies:
Q2. Activities that I do with my loved ones / others that give life meaning are:
Reasons why I enjoy these activities:
Q3. Beliefs I hold and religious activities I do that give life meaning are:
Reasons why my religion and personal beliefs are important:
Q4. How much I value my physical well-being in the following situations:
Q5. How much I value my mental well-being in the following situations:
Q6. How much I value my emotional well-being in the following situations:
Q7. My fears and worries about having a serious illness and about receiving medical care are:
Q8. If I am seriously ill and cannot speak, move around and make my own decisions one day...
Q9. If I have an injury or illness, and my doctors believe that I would have a low chance of recovery...
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...
Q11. Who I would want to be my Nominated Healthcare Spokesperson