Patient Advance Care Planning Form

Patient Advance Care Planning Form — Form Fields

This healthcare template includes 10 fields. Document a patient's wishes for future medical care including goals, values, and end-of-life preferences. Free to customize and use on ZenBuild.

• Patient Full Name (text, required)
• Date of Birth (text, required)
• Email Address (email, required)
• Healthcare Proxy Name (text, required)
• Healthcare Proxy Phone (text, required)
• Do You Have a Living Will or Advance Directive? (multiple choice, required) — options: Yes, No, In Progress
• What Matters Most to You in Your Medical Care? (long text, required)
• Situations You Would Consider Worse Than Death (long text, optional)
• Resuscitation Preference (CPR) (multiple choice, required) — options: Attempt resuscitation, Do not attempt resuscitation (DNAR), Discuss with provider
• Other Wishes or Instructions (long text, optional)