Hospice Needs Assessment Survey

When an illness no longer responds to curative treatment or when a patient wishes to discontinue such treatments, hospice is an empowering choice that provides comfort for patients and peace of mind for families. Hospice includes counseling that helps the patient and their family make informed decisions on their plan of care.

Complete this brief questionnaire to determine whether now might be the right time to consider hospice care for a loved one who is facing the challenges of a life-limiting condition.

During the past few months, has your loved one:
	Yes	No
Been hospitalized or visited the emergency room numerous times?	Been hospitalized or visited the emergency room numerous times?: *
Made increasingly frequent phone calls to his or her physician?	Made increasingly frequent phone calls to his or her physician?: *
Complained frequently about pain and other physical symptoms?	Complained frequently about pain and other physical symptoms?: *
Spent most of the day lying in bed or sitting in a chair?	Spent most of the day lying in bed or sitting in a chair?: *
Experienced one or more falls?	Experienced one or more falls?: *
Required assistance with getting out of bed, bathing, dressing, eating or walking?	Required assistance with getting out of bed, bathing, dressing, eating or walking?: *
Become tired more easily?	Become tired more easily?: *
Shown significant and ongoing weight loss?	Shown significant and ongoing weight loss?: *
Experienced shortness of breath even when resting?	Experienced shortness of breath even when resting?: *
Received a terminal prognosis from a physician with an estimated life expectancy of six months or less?	Received a terminal prognosis from a physician with an estimated life expectancy of six months or less?: *
Struggled with sadness or depression about his or her condition or quality of life?	Struggled with sadness or depression about his or her condition or quality of life?: *