VALUES HISTORY FORM
The Values History Form was developed at the Institute of Public Law, University of New Mexico School
of Law. The form is not a legal document, although it may be used to supplement a Living Will, a Durable
Power of Attorney for Health Care, or an Advance Directive for Health Care, if you have these. The
Values History provides a way for people to discuss and document their wishes and preferences so that
surrogate decision making, if it should become necessary, will reflect an individual's desires.
The Values History Form is not copyrighted, and you are encouraged to make additional copies for
friends and relatives to use.
Name ________________________________________________ Date ____________________
If someone assisted you in completing this form, please fill in his or her name, address, and relationship
to you.
Name _____________________________________________________________________________
Address ___________________________________________________________________________
Relationship ________________________________________________________________________
It is important that your medical treatment be your choice.
The purpose of this form is to assist you in thinking about and writing down what is important to you about
your health. If you should at some time become unable to make health care decisions, this form may help
others make a decision for you in accordance with your values.
The first section of this form provides an opportunity for you to discuss your values, wishes, and
preferences in a number of different areas such as your personal relationships, your overall attitude
toward life, and your thoughts about illness.
The second section of this form provides a space for indicating whether you have completed an Advance
Directive, e.g., a Living Will, Durable Power of Attorney for Health Care Decisions or Advance Directive
for Health Care, and where these documents may be found.
This form is not copyrighted; you may make as many copies as you wish. Developed by the Center for
Health Law and Ethics, Institute of Public Law, University of New Mexico School of Law, 1117 Stanford
NE, Albuquerque, New Mexico 87131.
OVERALL ATTITUDE TOWARD LIFE AND HEALTH
• What would you like to say to someone reading this document about your overall attitude toward life?
• What goals do you have for the future?
• How satisfied are you with what you have achieved in your life? What, for you, makes life worth
living?
• What do you fear most? What frightens or upsets you?
• What activities do you enjoy (e.g., hobbies, watching TV, etc.)?
• How would you describe your current state of health?
• If you currently have any health problems or disabilities, how do they affect: You? Your family? Your
work? Your ability to function?
• If you have health problems or disabilities, how do you feel about them? What would you like others
(family, friends, doctors) to know about this?
• Do you have difficulties in getting through the day with activities such as: eating? preparing food?
sleeping? dressing and bathing? etc.
• What would you like to say to someone reading this document about your general health?
PERSONAL RELATIONSHIPS
• What role do family and friends play in your life?
• How do you expect friends, family and others to support your decisions regarding medical treatment
you may need now or in the future?
• Have you made any arrangements for family or friends to make medical treatment decisions on your
behalf? If so, who has agreed to make decisions for you and in what circumstances?
• What general comments would you like to make about the personal relationships in your life?
THOUGHTS ABOUT INDEPENDENCE AND SELF-SUFFICIENCY
• How does independence or dependence affect your life?
• If you were to experience decreased physical and mental abilities, how would that affect your attitude
toward independence and self-sufficiency?
• If your current physical or mental health gets worse, how would you feel?
LIVING ENVIRONMENT
• Have you lived alone or with others over the last 10 years?
• How comfortable have you been in your surroundings? How might illness, disability or age affect this?
• What general comments would you like to make about your surroundings?
RELIGIOUS BACKGROUND AND BELIEFS
• What is your spiritual/religious background?
• How do your beliefs affect your feelings toward serious, chronic or terminal illness?
• How does your faith community, church or synagogue support you?
• What general comments would you like to make about your beliefs?
RELATIONSHIPS WITH DOCTORS AND OTHER HEALTH CAREGIVERS
• How do you relate to your doctors? Please comment on: trust; decision making; time for satisfactory
communication; respectful treatment.
• How do you feel about other caregivers, including nurses, therapists, chaplains, social workers, etc.?
• What else would you like to say about doctors and other caregivers?
THOUGHTS ABOUT ILLNESS, DYING AND DEATH
• What general comments would you like to make about illness, dying and death?
• What will be important to you when you are dying (e.g., physical comfort, no pain, family members
present, etc.)?
• Where would you prefer to die?
• How do you feel about the use of life-sustaining measures if you were: suffering from an irreversible
chronic illness (e.g., Alzheimer's disease)? terminally ill? in a permanent coma?
• If you were terminally ill, would you want hospice services to ensure optimal pain and symptom
management and support for your family and loved ones?
• What general comments would you like to make about medical treatment?
FINANCES
• What general comments would you like to make about your finances and the cost of health care?
• What are your feelings about having enough money to provide for your care?
FUNERAL PLANS
• What general comments would you like to make about your funeral and burial or cremation?
• Have you made your funeral arrangements? If so, with whom?
OPTIONAL QUESTIONS
• How would you like your obituary (announcement of your death) to read?
• Write yourself a brief eulogy (a statement about yourself to be read at your funeral).
• What would you like to say to someone reading this Values History Form?
LEGAL DOCUMENTS
• What legal documents about health care decisions have you signed?
• Living Will? ___ Yes ___ No
• If yes, where can it be found? Name, Address and Phone Number.
• Durable Power of Attorney for Health Care Decisions? ___ Yes ___ No
• If yes, where can it be found? Name, Address and Phone Number.
• Advance Directive for Health Care? ___ Yes ___ No
• If yes, where can it be found? Name, Address and Phone Number.
• Other? ___ Yes ___ No
• If yes, where can it be found? Name, Address and Phone Number.
