Is It Time to Consider Hospice Care? Let’s Take a Thoughtful Look Together.
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1-7. Evaluate the Current Situation and Care Readiness
Choose as many as are suitable for you:
A
Patient has a life limiting illness
B
Patient is undergoing aggressive treatment and prepared to stop
C
Patient undergoing aggressive treatment and is unprepared to stop
D
Patient and family goals are to relieve symptoms and provide comfort
E
There is progression of the primary disease process
F
There have been multiple ER visits or hospitalizations over the last 6 months
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2-7. Select the most appropriate description of the patient's ambulation.
Pick the one option that applies to you:
A
Reduced ambulation
B
Mainly sits or lies
C
Mainly in bed
D
Totally bed bound
E
Normal ambulation
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3-7. Select the most appropriate description ofthe patient's Housework abilities.
Pick the one option that applies to you:
A
Able to participate and complete housework
B
Mainly sits or lies
C
Patient is unable to complete housework
D
Totally bed bound
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4-7. Selection the most appropriate description ofthe patient's self-care abilities.
Pick the one option that applies to you:
A
Occasional assistance necessary
B
Requires a considerable amount of assistance with self care
C
Patient is unable to complete housework
D
Requires total care
E
No assistance necessary
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5-7. Select the most appropriate description of the patient's dietary intake.
Pick the one option that applies to you:
A
Normal intake - 3 full meals daily
B
Reduced inatake - 1 to 2 small meals daily or small portions of each meal
C
Minimal Intake - bites of food only, small sips
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6-7. Select one of the following level ofconsciousness options.
Pick the one option that applies to you:
A
Fully conscious without confusion
B
Fully conscious with some confusion/forgetfulness
C
Some drowsiness (prolonged sleeping, napping during the day)
D
Drowsy or unresponsive
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7-7. The patient requires assistance withthe following acts of daily living.
Choose as many as are suitable for you:
A
Personal hygiene and grooming
B
Dressing and undressing
C
Patient undergoing aggressive treatment and is unprepared to stop
D
Transferring
E
Toileting
F
Ambulation
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Total Score
[score quantity]
.
How would you like to begin the introduction to hospice services?
A
At-Home
We will visit you at the address you provided.
B
By Phone
We will call you at a convenient time.
C
By Video Call
We will schedule a video meeting at a time that works best for you.
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At-Home. We will visit you at the address you provided.
Please enter your address and choose a date and time that is convenient for you.
Your address
Phone number
Day & time
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By Phone. We will call you at a convenient time.
Please provide your phone number and select a date and time convenient for you.
Phone number
Day & time
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By Video Call. We will schedule a video meeting at a time that works best for you.
Please enter your email address and choose a date and time that is convenient for you.
Email address
Day & time
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