Palliative Assessment Quiz Form

* = Required Information

Name *

Address *

Email *

Phone *

Been hospitalized or gone to the emergency room several times in the past six months?
YES NO

Been making more frequent phone calls to your physicians?
YES NO

Started taking medication to lessen physical pain?
YES NO

Fallen several times over the past six months?
YES NO

Started needing help from others with:

Bathing
YES NO

Dressing
YES NO

Eating
YES NO

Getting out of bed
YES NO

Walking
YES NO

Started feeling weaker or more tired?
YES NO

Experienced weight loss making clothes noticeably looser?
YES NO

Noticed a shortness of breath, even while resting?
YES NO

Been told by a doctor that life expectancy is limited?
YES NO