End of Life Care Planning

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* 1. I have completed a “Healthcare Power of Attorney”.

Yes

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* 2. I have completed a “Mental Healthcare Power of Attorney”.

Yes

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* 3. I have completed a “Living Will”, known as an advance directive (can be Five Wishes or another form).

Yes

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* 4. I have discussed my wishes with my loved ones and physicians and given them copies of these documents.

Yes

If No, what is stopping you?

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* 5. I have registered these documents on the Arizona Advance Directives Registry.

Yes

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* 6. I have attended a workshop on end of life care planning.

Yes

If Yes, please let us know where and when.

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* 7. I have participated in 1:1 coaching/consultation regarding end of life care planning.

Yes

If Yes, with whom?

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* 8. I would like to share my story about having the conversation with my loved one(s).

Thank you for taking time to complete this questionnaire. We just have a few more questions.

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* 9. I most identify as:

Female

Male

Other

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* 10. My age range is:

<18

18-24

25-34

35-44

45-54

55-64

65-74

75-84

85 or better

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* 11. The category that best describes me

Hispanic/Latino/a (Ex. Mexica Am, Cuban, Puerto Rican)

Black/African Am. (Ex. African American, Jamaican, Somalian, Haitian)

Asian (Ex. Chinese Filipino, Asian Indian, Korean, Vietnamese)

American Indian/ Alaska (Ex. Native (Ex. Navajo, Tohono O’odham)

White/Caucasian (Ex. German, Irish, English, Italian, Polish)

Middle Eastern or North African (Ex. Lebanese, Syrian, Moroccan)

Native Hawaiian or other Pacific Islander (Ex. Samoan, Fijian)

Some other race, ethnicity or origin ____________________

Other (please specify)

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* 12. My home zip code is:

If you have any questions or comments please call Thoughtful Life Conversations Director at 602-445-4312 or email: tlc@thoughtfullifeconversations.org.

Thank you again for your time. We greatly appreciate it.