It can be difficult to tell when hospice is an appropriate choice. Please fill out the form below. Name First Last Email NumberRoom # Age Primary Diagnosis Has the patient been admitted into the hospital within the last 6 months?YesNoHave there been any reoccurring infections in the last month?YesNoHave there been any reoccurring falls reported in the las 6 months?YesNoHas there been a greater than 10% weight loss in the last 3 - 6 months?YesNoHas there been a decrease in appetite with in the last 3 - 6 months?YesNoHas there been any difficulty swallowing pills or solid food?YesNoHas there been an increase in Dependency on ADL’s? If so please select all that apply.YesNo Walking Transfer Feeding Bathing Toileting Dressing Has there been any skin breakdown or slow healing wounds?YesNoHas there been any presence of pain, anxiety or agitation? If so please select all that apply.YesNo Pain Anxiety Agitation Has there been withdrawal? i.e. not interested in things around them or not wanting to participate in activities/events?YesNoHow many hours of sleep do they get in a 24 hour period?456789101112+Are there any other areas of concern? Δ
