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What Mom & Dad Want

A Gentle Questionnaire for Aging Parents

Have the important conversations before a crisis forces them. This questionnaire helps your parents share their wishes, preferences, and values in their own words, so you can honor them when it matters most.

How to Use This

Give this to your parent to fill out on their own, or sit with them and write their answers together. There are no wrong answers. The goal isn't to plan for death, it's to understand how they want to live.

ParentCareGuide.com

About Me

Let's start with the basics, things that will help your family understand you better.

A Note to Parents

Your children are asking these questions because they love you and want to respect your wishes. This isn't about taking control, it's about understanding. Your voice matters, and this is your chance to share it.

My full legal name:

Date of birth:

Social Security Number: (Keep this copy secure)

Medicare/Insurance Number:

What Makes Me, Me

Things that bring me joy or comfort: Music, foods, activities, places, people...

Things I really don't like or that upset me:

My daily routines that are important to me: Morning coffee ritual, evening news, Sunday calls, etc.

My Values & Beliefs

Understanding what matters most to you helps your family make decisions that honor who you are.

What matters most to me in life: Independence, family, faith, dignity, comfort, being at home, etc.

My religious or spiritual beliefs: And how you'd like them honored

Things I would want people to know about how I want to be treated:

Independence Scale

How important is independence to you compared to safety?

1

Safety is most important

2

3

Balance both

4

5

Independence is most important

What does "quality of life" mean to you? What makes life worth living for you personally?

Things I would NOT want, even if others think it's best for me:

How I Want to Live

These questions help your family understand your preferences for daily life and living arrangements.

If I Need Help With Daily Life

My preference for who provides my care:

Family members

Hired caregiver at home

Assisted living facility

Other: __________

If I need to move out of my home, my preferences are: Rank in order: 1 = most preferred

Live with family member: _______________

Independent living community

Assisted living facility

Stay in my home with full-time help

If I move, I would want to stay close to:

Things that are important in my living environment:

Access to outdoors/garden

Privacy

Social activities

Pets allowed

Near family

Near my church/community

Anything else about my living preferences:

My Medical Preferences

These questions are not about making immediate decisions, they're about helping your family understand your wishes.

Important Note

This questionnaire is not a legal document. For legally binding medical directives, please work with an attorney to create an Advance Directive, Living Will, and Healthcare Power of Attorney.

My primary care doctor:

Name and phone number

My preferred hospital:

In a Medical Crisis

If I'm very sick or injured, I would want my family to prioritize:

Extending my life as long as possible

Quality of life over quantity

Comfort and pain management

Following doctor recommendations

The person I trust to make medical decisions if I cannot:

Name:

Phone:

Things I would want my medical decision-maker to know:

Do you have these legal documents in place?

Healthcare Power of Attorney

Living Will / Advance Directive

POLST/MOLST form

DNR order (if desired)

Financial & Practical Matters

Having this information organized helps your family support you without scrambling.

Important People

The person I trust to manage my finances if needed:

Name:

Relationship:

My attorney:

My accountant/financial advisor:

Legal Documents

Do you have these documents? Where are they located?

□ Will

□ Trust

□ Power of Attorney

□ Life Insurance Policy

□ Property Deeds

Accounts & Access

Banks where I have accounts:

Key bills on autopay / Important recurring expenses:

Security Tip

Store this document and related passwords in a secure location. Consider using a password manager and sharing access with your trusted person.

Personal Wishes & Legacy

These questions help your family understand what matters to you beyond the practical.

Personal Items

Items that have special meaning to me and who I'd like to have them:

Family items, photos, or heirlooms I want to make sure are preserved:

Stories & Memories

Stories about our family I want to make sure get passed down:

Things I want my grandchildren (or future generations) to know:

Life lessons I've learned that I'd like to share:

End of Life Wishes

These are hard questions. Take your time. Your family will be grateful for your guidance when the time comes.

Why This Matters

When you share your end-of-life wishes clearly, you give your family an incredible gift: the ability to honor you without guilt or uncertainty. This isn't morbid, it's loving.

When I'm nearing the end of life, I would want:

To be at home if possible

Hospice care for comfort

Family around me

Quiet and peaceful environment

Music playing

Spiritual/religious support

After I pass, I would prefer:

Burial

Cremation

Body donation to science

Other: __________

For my memorial/funeral, I would want: Type of service, location, music, readings, who should speak, etc.

People who should be notified when I pass:

Anything else I want my family to know:

In My Own Words

This page is yours. Write anything you want your family to know, a letter, advice, memories, gratitude, or simply how much they mean to you.

To my family...

Signature

Date