Advance Directive Questionnaire
Advance directive questionnaire recording a person's care wishes, decision-maker, and existing documents for their own records and care team.
A ready-to-use healthcare & clinical form for small teams who need a reliable intake process: 16 questions, 3 pages, 2 conditional rules.
- Questions
- 16
- Pages
- 3
- Layouts
- classic · card
- Time to complete
- ≈ 8 min
- Conditional rules
- 2
Searches this template answers
- advance directive questionnaire
- advance care planning form
- living will questionnaire
- healthcare proxy form
- end of life wishes form
- advance directive intake form
Also filed under
Live preview and test console
This is the real form. Answer it to test the 2 conditional rules — nothing is sent or stored.
Page 1 of 3 — About you and your decision-maker
Every question on this page is currently visible.
Compliance checklist
- Payment items priced — passingEvery payment question charges a real amount, so a submission always records a payment.
- Conditional logic resolves — passingEvery rule points at a question or page that exists in this template.
- Medical disclaimer present — passingThis form does not provide medical advice, diagnosis or treatment. Information you share here is not a substitute for care from a qualified clinician. In an emergency, contact your local emergency service immediately.
- Question labels unique — passingLogic and exports address questions by label, so duplicates are ambiguous.
What happens after submit: nothing is stored in this preview. On your own copy, every response triggers an instant email notification and lands in your response dashboard, ready to export or forward.
Happy with it? Take a copy into your workspace — every question, rule and setting comes with it.
Who this template is for
Advance Directive Questionnaire is built for small teams who need a reliable intake process who need to collect the same complete information from everyone.
- Small teams who need a reliable intake process working in healthcare & clinical.
- Teams who need to collect the same complete information from everyone without writing code or paying for a custom build.
- Anyone replacing chasing missing details over email with one structured record per enquiry.
- Respondents are the people you send it to — the form asks them 16 questions across 3 screens.
- Mobile-heavy audiences, thanks to the one-question-per-screen card layout.
Why this form is useful
It removes the cost of chasing missing details over email and turns each submission into a record your team can act on immediately.
- 11 questions are required, so submissions arrive complete instead of needing a follow-up email.
- It captures a phone number for urgent follow-up.
- It accepts a document or photo upload as evidence.
- It pins the request to a specific date.
- It allows multiple selections without free text.
- Conditional logic hides 2 questions until they are relevant — shorter forms convert better than long ones.
- Splitting the form across 3 pages keeps each screen short and shows respondents how much is left.
- Every response is stored, searchable and exportable, so nothing depends on one person's inbox.
How to use this template
From copy to live form is a few minutes of work, and every step is reversible.
- 1Press “Use this template” — a fresh copy of Advance Directive Questionnaire lands in your workspace, ready to edit.
- 2Rename or delete any question, and change what is required. Nothing here is fixed.
- 3Open Notifications and add the email addresses that should be alerted on each submission; add an auto-reply to the respondent if the form collects an email address.
- 4Check the upload limits on the file question so respondents can attach what you actually need.
- 5Publish it, then either share the link directly or paste the embed snippet into your site — the embedded form resizes to fit and loads no marketing or advertising trackers.
- 6Watch responses land in Submissions, where you can filter, label and export them to CSV or PDF.
Logic and conditions blueprint
Exactly how this form behaves as it is answered — 2 conditional rules ship with it.
- Features advanced show logic: if “Do you have wishes about artificial nutrition or hydration?” is Yes, described below, the form dynamically exposes “Describe those wishes”. Otherwise that question never appears.
- Features advanced show logic: if “Do you already have a signed, legal advance directive or living will?” is Yes, the form dynamically exposes “Upload your existing document, if any”. Otherwise that question never appears.
- All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other.
About this template
What makes an advance directive legally valid depends on where the person lives, and this questionnaire is not that legal document. It exists to record a person's wishes for their own records and for the care team to read, in plain language, alongside whatever formal paperwork applies in their jurisdiction. Page one records who the person is, their state or jurisdiction, and who they want making healthcare decisions on their behalf if they cannot make them, including that person's contact details. Page two asks about the wishes themselves in the person's own words: views on life-sustaining treatment, on artificial nutrition or hydration, opening a longer box only when there is more to say, and any personal or religious beliefs that should guide care. The final page asks whether a signed, legal advance directive already exists, whether this has been discussed with a doctor, and who should receive a copy. Anyone completing this should still check what their jurisdiction actually requires for a document to be legally binding, and talk to a lawyer or their care team if they are unsure.
What this form asks
Every question is editable — rename it, make it optional, or delete it entirely.
Page 1 — About you and your decision-maker
- Full namerequired
- Date of birthrequired
- State or jurisdiction you live inrequired
- Name of your healthcare decision-makerrequired
- Relationship to yourequired
- Their phone numberrequired
- Alternate decision-maker's name and contact, if any
Page 2 — Your wishes for care
- If you were unable to make decisions, would you want life-sustaining treatment attempted?required
- Describe your wishes in more detail
- Do you have wishes about artificial nutrition or hydration?required
- Describe those wishes
Page 3 — Existing documents and sharing
- Do you already have a signed, legal advance directive or living will?required
- Upload your existing document, if any
- Has this been discussed with your doctor?required
- Who should receive a copy of these wishes?required
- Anything else your care team should know
16 questions in total.
Example of a completed advance directive questionnaire
A sample record showing how a person documents their care wishes for their own file and care team.
- Full name
- Walter Higgins
- State or jurisdiction you live in
- Oregon
- Name of your healthcare decision-maker
- Denise Higgins
- Relationship to you
- Daughter
- If you were unable to make decisions, would you want life-sustaining treatment attempted?
- Depends on circumstances, described below
- Describe your wishes in more detail
- Comfort-focused care if there is no reasonable chance of recovery
- Do you have wishes about artificial nutrition or hydration?
- Yes, described below
- Do you already have a signed, legal advance directive or living will?
- No
- Has this been discussed with your doctor?
- No
- Who should receive a copy of these wishes?
- Primary care provider, Family members
Sample data — no real people, addresses or records are shown. This example makes no claim about legal validity in any jurisdiction.
How the form changes as it's filled in
This template ships with 2 conditional rules, grouped into 2 behaviours driven by 2 questions. Everything below is already set up — edit or delete any rule once the template is in your workspace.
Driven by “Do you have wishes about artificial nutrition or hydration?”
- Reveals questions
If “Do you have wishes about artificial nutrition or hydration?” is Yes, described below, the form reveals “Describe those wishes”.
Driven by “Do you already have a signed, legal advance directive or living will?”
- Reveals questions
If “Do you already have a signed, legal advance directive or living will?” is Yes, the form reveals “Upload your existing document, if any”.
Set it up step by step
- 1
Say plainly that this is not the legal document itself
Put a line above page one making clear that validity depends on jurisdiction and this record supports, not replaces, the formal paperwork.
- 2
Confirm the decision-maker actually agreed
Naming someone here works best when that person already knows and has accepted the role, not when they hear about it later.
- 3
Route it to the care team, not a filing cabinet
The point of this record is that a clinician can find and read it quickly if the person cannot speak for themselves.
- 4
Revisit it after a major health change
Wishes recorded years ago can shift; prompt a review after a new diagnosis or a significant change in health.
Mistakes to avoid
- Presenting this questionnaire as a legally binding directive on its own.
- Naming a decision-maker without confirming they know and accept the responsibility.
- Filing the answers without sharing a copy with the people who need to act on them.
What it pairs with
Most teams don't run this form on its own. These are the forms and systems it sits next to.
What to do with the responses
Share a copy with the people selected on the form, confirm what your jurisdiction requires for a legally binding directive, and revisit the answers if the person's health or wishes change.
Works in both layouts
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Privacy & compliance
This form collects health information. Keep access limited to the people who need it, turn on encrypted answers for the clinical questions, and set a retention window so records don't sit in the dashboard forever.
Frequently asked questions
Is this form legally binding?
That depends entirely on your jurisdiction's requirements, which vary; this questionnaire records wishes for the person's own file and care team, not as a substitute for a jurisdiction's legal form.
Does the care team have to follow what is recorded here?
It is meant to inform decisions and give the decision-maker and clinicians a clear written statement of wishes; how it is used alongside legal documents depends on local law and your organization's policy.
Should a lawyer be involved?
For the legally binding document, most jurisdictions have their own required form or process; a lawyer or your care team can advise on what applies where the person lives.
Can these answers be updated later?
Yes, and they should be whenever the person's health, wishes or decision-maker changes; complete a fresh questionnaire rather than editing the old one.
Is the Advance Directive Questionnaire template free to use?
Yes. You can preview and test Advance Directive Questionnaire on this page without an account, and take a copy into your own HelloForms workspace on the free plan. There is nothing to install and no card required to publish it.
What does the Advance Directive Questionnaire template ask for?
It asks 16 questions across 3 pages, 11 of which are required. Every question is listed in full further down this page, and each one can be renamed, reordered, made optional or deleted after you copy the template.
Can I edit the Advance Directive Questionnaire form after copying it?
Yes — the copy is entirely yours. Change wording, add or remove questions, switch between the classic and card layouts, restyle it to match your brand, and set who gets notified on each submission.
How does the conditional logic in this healthcare & clinical form work?
2 conditional rules ship with the template: Features advanced show logic: if “Do you have wishes about artificial nutrition or hydration?” is Yes, described below, the form dynamically exposes “Describe those wishes”. Otherwise that question never appears. Features advanced show logic: if “Do you already have a signed, legal advance directive or living will?” is Yes, the form dynamically exposes “Upload your existing document, if any”. Otherwise that question never appears. All 2 rules are editable in the Logic tab, and the built-in checker warns about rules that contradict each other. All rules are editable in the Logic tab.
Where do responses to the Advance Directive Questionnaire form go?
Submissions land in your workspace under Submissions, where you can search, filter, label and export them to CSV or PDF. You can also email a notification to your team on every submission and send the respondent an auto-reply.
Can I embed the Advance Directive Questionnaire form on my own website?
Yes. Publish the form and paste the embed snippet into any page or share the direct link. The embedded form resizes to fit its container and loads no advertising or marketing trackers inside the iframe.
Can respondents upload files?
Yes. This template includes a file upload question, so respondents can attach documents or photos with their answers. You can adjust the accepted file types and size limits on that question.
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