Assessment

Is now the right time for hospice care?

Answering the following questions will help you consider if the time is right to talk to your family and physician about hospice care.

How many statements apply to your situation?

Step 1 of 2

50%

Lately, I need assistance with:(Required)

Getting out of bed

Walking

Preparing meals

Eating

Getting dressed

Taking a shower or bath

How many statements apply to your situation?(Required)

I've become weaker and more fatigued

I've become short of breath, even at rest

I've lost weight

I've fallen several times in the recent months

I've been hospitalized or needed emergency care several times in the past year

The pain medications I take are not working as well as they used to

I spend a good part of my day lying in my bed or just sitting

I am experiencing swelling

I am on oxygen most of the time

I am calling my doctor more often than I used to

My doctor has said that my life expectancy is limited

Name(Required)

First Last

Phone(Required)

Email(Required)

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3120 Fannin St
Beaumont, TX 77701

Fax: 409.299.3409