Advance Care Planning Form

姓名 / Full Name*
電話 / Phone Number*
Please enter a valid phone number.
電郵 (可選填) / Email (optional)
example@example.com
您希望諮詢師就哪些免費服務與您聯繫？檢查所有適用。 / What free services would you like to have a counselor reach out to you about? Check all that apply.

健康和家庭護理 / Health & Home Care老人住宅 / Senior Housing活動中心 / Activity Centers就業服務 / Employment Services社會服務 / Social Services清潔服務 / Cleaning Services營養服務 / Nutrition ServicesHICAP (健康保險諮詢和宣傳計劃 / Health Insurance Counseling and Advocacy Program)電腦學習計劃 / Digital Learning Program申請糧食券 / Applying for Food Stamps申請紅藍卡 / Applying for Medicare尋找會說中文的醫生 / Finding a Chinese-speaking doctor
您是否已經簽署正式的文件來指定您的醫療決策者？您的醫療決策者是一位您的家庭成員或朋友，他/她將在您病重到無法自己作出醫療決定時為您作出醫療決定。/ Have you SIGNED official papers naming a medical decision maker? A medical decision-maker is a family member or friend who can decide for you if you become too sick to make your own decisions.*

是 Yes否 No
您是否已經和您的醫療決策者討論過，當您病重或接近生命盡頭時，您想接受怎樣的醫療護理？/ Have you TALKED to your medical decision-maker about the kind of medical care you would want if you were very sick or near the end of life?*

是 Yes否 No
您是否已經和您的醫生討論過，當您病重或接近生命盡頭時，您想接受怎樣的醫療護理？/ Have you TALKED to your doctor about the kind of medical care you would want if you were very sick or near the end of life?*

是 Yes否 No
您是否簽署了正式的文件，以書面形式表達您在病重或接近生命盡頭時，您想接受醫療護理的意願？/ Have you SIGNED official papers putting your wishes in writing about the kind of medical care you would want if you were very sick or near the end of life?*

是 Yes否 No
請問您多大年紀？/ What is your age?*

18 至 30 歲 / 18 - 3031 至 50 歲 / 31 - 5051 至 65 歲 / 51 - 6566 至 80 歲 / 66 - 8081 至 90 歲 / 81 - 9090 歲以上 / Over 90
你住在舊金山嗎？/ Do you live in San Francisco?*

是 Yes否 No
請問您在美國居住了多長時間？ / How many years have you lived in the US?*

少於 5 年 / Less than 55 至 10 年 / 5 - 1020 年以上 / More than 20
您是否想讓我們聯繫您，幫您了解更多有關我們免費預先醫療指示計劃服務的信息？/ Would you like to be contacted to learn more about our free Advance Care Planning services?*

是 Yes否 No
您是從哪裡聽說這個網站的？/ Where did you hear about this web page?*

看了一個視頻廣告 Watched a video ad微信 WeChat臉書 Facebook電子郵件 Email通訊 Newsletter報紙 Newspaper健康講座 Health WorkshopInstagram推特 Twitter口口相傳 Word of Mouth其他 Other
如您在上一個問題中回答“其他”，請問您是從哪裡聽說過這個網站的？ / If you answered "Other" in the previous question, where else did you hear about this page?
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