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Quality of Life-Advance Directive
Full Name
*
Email:
*
Date
*
ACTIVITIES OF DAILY LIVING
Q1: Feeding Myself
If I can no longer chew, swallow, or feed myself independently...
*
A
Permanent Assistance (I am comfortable receiving help indefinitely)
B
Trial Period (I want help tried, but ONLY for a limited timeframe)
C
No Intervention (Comfort care only; let nature take its course)
Q2: Dressing Myself
If I can no longer pick out clothes or physically dress myself...
*
A
Permanent Assistance (I am comfortable receiving help indefinitely)
B
Trial Period (I want help tried, but ONLY for a limited timeframe)
C
No Intervention (This is essential to my dignity)
Q3: Toileting and Personal Hygiene
If I lose control of my bladder/bowels or need full assistance in the restroom...
*
A
Permanent Assistance
B
Trial Period
C
Quality of Life Limit (This is essential to my dignity)
Q4: Communicating My Wishes
If I can no longer speak, write, or use technology to express my needs...
*
A
Permanent Assistance
B
Trial Period
C
Quality of Life Limit (I absolutely must be able to communicate)
Q5: Mobility & Walking
If I can no longer walk or move out of bed independently...
*
A
Permanent Assistance
B
Trial Period
C
Quality of Life Limit (Walking and independent mobility are essential to my quality of life)
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