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 Your Name: (required) Your Email: (required) Select Your Location: (required) WichitaFarmingtonSend to Taylor Subject: Hospice Quiz Δ