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 29http://www.theconsumervoice.org http://www.coasc.org