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COUNCIL ON AGING - SOUTHERN CALIFORNIA

HEALTHCARE

My Personal Directions for Living
Name: __________________________________________ Date: _______________________________
To my caregivers paid and unpaid: I am recording my personal preferences and information about myself, in case I need long-term care services in my home or in a long-term care facility. I hope this information will be useful to those who assist me. Please always talk to me about my day-to-day life to see what
it is that I want and enjoy. However, the information below may provide some help in understanding me
and in providing my care.
I want my caregivers to know: ___________________________________________________________
The way I like to awaken & begin my day: ___________________________________________________
The way I relax and prepare to sleep at night: _______________________________________________
Activities I enjoy: ______________________________________________________________________
Things that I would like to have in my room: ________________________________________________
Foods that I enjoy: _____________________________________________________________________
Things I do not like: ____________________________________________________________________
I become anxious when:_________________________________________________________________
Things that calm or soothe me: ___________________________________________________________
Things that make me laugh: _____________________________________________________________
Religious Preferences: __________________________________________________________________
Other: _______________________________________________________________________________
At the end of my life, I would like: _________________________________________________________
_____________________________________________________________________________________
For more information about me please talk to: ______________________________________________
_____________________________________________________________________________________
Reprinted from the National Consumer Voice for Quality Long-Term Care, www.theconsumervoice.org

Council On Aging - Southern California | 714-479-0107 | www.coasc.org	 Answers Guide 2017

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Table of Contents for the Digital Edition of Council on Aging Answers 2017

Contents
Council on Aging Answers 2017 - Intro
Council on Aging Answers 2017 - Cover1
Council on Aging Answers 2017 - Cover2
Council on Aging Answers 2017 - 1
Council on Aging Answers 2017 - Contents
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Council on Aging Answers 2017 - Cover3
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