End of Life Care Planning Question Title * 1. I have completed a “Healthcare Power of Attorney”. Yes No OK Question Title * 2. I have completed a “Mental Healthcare Power of Attorney”. Yes No OK Question Title * 3. I have completed a “Living Will”, known as an advance directive (can be Five Wishes or another form). Yes No OK Question Title * 4. I have discussed my wishes with my loved ones and physicians and given them copies of these documents. Yes No If No, what is stopping you? OK Question Title * 5. I have registered these documents on the Arizona Advance Directives Registry. Yes No OK Question Title * 6. I have attended a workshop on end of life care planning. Yes No If Yes, please let us know where and when. OK Question Title * 7. I have participated in 1:1 coaching/consultation regarding end of life care planning. Yes No If Yes, with whom? OK Question Title * 8. I would like to share my story about having the conversation with my loved one(s). OK Thank you for taking time to complete this questionnaire. We just have a few more questions. OK Question Title * 9. I most identify as: Female Male Other OK Question Title * 10. My age range is: <18 18-24 25-34 35-44 45-54 55-64 65-74 75-84 85 or better OK Question Title * 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) OK Question Title * 12. My home zip code is: OK If you have any questions or comments please call Thoughtful Life Conversations Director at 602-445-4312 or email: tlc@thoughtfullifeconversations.org. OK Thank you again for your time. We greatly appreciate it. OK SBMIT