If you’re not sure whether you or your loved one might be eligible to receive hospice care, this brief questionnaire might help.

Have you or a loved one…

1. Been hospitalized or gone to ER several times in past 6 months?
YesNo


2. Been making more frequent phone calls to your physicians?
YesNo


3. Started taking medication to lessen physical pain?
YesNo


4. Started spending most of the day in a chair or bed?
YesNo


5. Fallen several times over the past 6 months?
YesNo


6. Started needing help with one or more of these: bathing, dressing, eating, getting out of bed, or walking?
YesNo


7. Started feeling weaker or more tired?
YesNo


8. Experienced weight loss making clothes noticeably looser?
YesNo


9. Noticed a shortness of breath, even while resting?
YesNo


10. Been told by a doctor that life expectancy is limited?
YesNo

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