What is the advance directive worksheet form template?
Most people have opinions about the care they'd want at the end of life, but few write them down. When the time comes, families are often left guessing in a hospital corridor. A worksheet like this one makes it easier to have that conversation early, and to carry your answers onto your state's or country's official form.
The worksheet has three sections. You start with your details and whether you already have an advance directive or living will. Next you name a "Health care agent" and say whether you've talked with them. Choosing "Name an alternate agent" opens fields for a backup. The treatment page asks "What matters most to you about your quality of life?" and then covers CPR, a breathing machine, tube feeding, dialysis, antibiotics and going to hospital in one grid. The same section goes on to organ donation, spiritual wishes and who should have a copy.
The worksheet says clearly that it isn't a legal document by itself. Your answers are saved as a signed PDF in your FileIt vault, where you and the people you share with can find them.
- Best for
- Adults planning ahead, families, hospices, care homes and advance care planning sessions
- Filled in by
- The person whose wishes these are, ideally after talking with family
- Time to complete
- 20–30 minutes
- Includes
- Agent and alternate, treatment grid, comfort care, organ donation, spiritual wishes
Who uses a advance directive worksheet form?
- Preparing to fill in your state's official advance directive form
- Starting a conversation with a parent or partner about their wishes
- A hospice or care home helping residents record their preferences
- An estate planning client gathering their thoughts before a meeting
- Reviewing your wishes after a new diagnosis or a big life change
Questions on this advance directive worksheet form
34 questions over 3 pages · includes signature, file upload, conditional questions, multiple pages, ratings.
1 About you
- Your name*
- Date of birth*
- Phone
- Your main doctor
- Address
- Do you already have an advance directive or living will?*
- Where is it kept, and when was it signed? asked only when it applies
- A copy of it asked only when it applies
2 Health care agent
- Health care agent*
- Relationship to you*
- Agent's phone*
- Agent's email
- Have you talked with them about your wishes?* Yes · Not yet, but I plan to · No
- Backup agent* Name an alternate agent · No alternate for now
- Alternate agent* asked only when it applies
- Relationship to you* asked only when it applies
- Alternate agent's phone* asked only when it applies
- Is there anyone you do not want making decisions for you?
3 Treatment & other wishes
- What matters most to you about your quality of life?*
- If I were seriously ill and not expected to recover, my wishes about these treatments are:* I want this · Try it, stop if it isn't helping · I don't want this · My agent decides
- Pain and comfort* Keep me comfortable even if it makes me sleepy or shortens my life · Keep me comfortable but as alert as possible · I'm not sure yet
- Where would you prefer to be cared for near the end of life? At home · In a hospice · In hospital · In a care home · No preference
- Anything else about treatment
- Organ and tissue donation* I'd like to donate any organs or tissues · Only certain organs or tissues · I don't want to donate · I'll leave it to my agent or family
- Which ones?* asked only when it applies
- Are you on a donor registry?
- Spiritual or religious wishes
- Faith leader or community to contact
- Other wishes
- Who should have a copy of my wishes?
- When I'd like to review this
- Your signature*
- Date*
The advance directive worksheet form, page by page
1 About you
A note explains that this is a worksheet and not a legal directive. "Your name" and "Date of birth" are required, along with "Do you already have an advance directive or living will?" A yes asks where it's kept and offers an upload for a copy.
2 Health care agent
A short explanation of what an agent does comes first. The "Health care agent", their relationship and phone are required, and their email is optional. "Have you talked with them about your wishes?" is required. "Backup agent" lets you choose "Name an alternate agent", which opens the alternate's name, relationship and phone. An optional box asks if there's anyone you don't want making decisions.
3 Treatment & other wishes
The required "What matters most to you about your quality of life?" comes before the treatment grid. For each treatment you choose "I want this", "Try it, stop if it isn't helping", "I don't want this" or "My agent decides". "Pain and comfort" is required. "Where would you prefer to be cared for near the end of life?" and a free-text box are optional. "Organ and tissue donation" is required. "Only certain organs or tissues" asks "Which ones?". Optional questions cover donor registration, "Spiritual or religious wishes", a faith leader to contact, "Other wishes" and who should have a copy. A review date, signature and date close the worksheet.
Make the template yours
- Add a link to your state's official advance directive form in the opening note
- Add treatments your patients often ask about, such as blood transfusions
- Rename "Health care agent" to the term used where you are, such as health care proxy or lasting power of attorney
- Remove the signature if you only use the worksheet to prepare for a conversation
- Set the vault folder to the family member's own folder so their wishes sit with their other documents
- Translate the worksheet for families who'd rather think about this in their first language
Tips for a better advance directive worksheet form
- Talk with your agent before you name them, and give them a copy
- Use "Try it, stop if it isn't helping" if your answer would depend on how things go
- Revisit your answers after a diagnosis, a move, or the loss of someone close
- Ask your doctor to explain any treatment you're unsure about before you decide
- Complete your official form with the right witnesses or notary for where you live
Every response becomes a PDF in your vault
Your answers become a signed PDF titled with your name, filed in the vault folder you chose, with a copy of any existing directive attached. If you set it up for someone else, such as a parent, you're emailed when they finish and they can receive their own copy.
Because the PDF sits in your FileIt vault, you can find it quickly when it matters. Send the worksheet again whenever your wishes change, and the dated versions stay side by side.
- Start from this template. It opens in the FileIt Forms designer — change any question, add pages, set the rules for when questions appear.
- Share it. Turn on a public link, or send it to people by email, each with their own link. They don’t need a FileIt account.
- Get the answers as PDFs. Each response is saved as a PDF in the vault folder you choose, with uploaded files attached — and listed in a Responses table you can export to CSV.
Advance directive worksheet form: frequently asked questions
Is this a legal advance directive?
No. It's a worksheet to help you decide and record your wishes. Each state or country has its own official form and signing rules. FileIt doesn't give legal or medical advice.
Can I name a backup agent?
Yes. Choosing "Name an alternate agent" opens fields for a second person's name, relationship and phone.
Can I change my answers later?
Yes. Fill in the worksheet again whenever your wishes change. Each version is saved as its own dated PDF.
Can I upload the directive I already have?
Yes. Answer yes to having one and you can upload up to two files, such as a scan or a PDF.
Is the worksheet free?
Yes. It's a starter template in the FileIt Forms app, available on every plan, including the free one.