Is it time for Hospice? 1. been hospitalized or visited the ER multiple times in the past 6 months? Yes No 2. initiated more phone calls to your physicians? Yes No 3. fallen multiple times over the past 6 months? Yes No 4. started to take medication to lessen physical pain? Yes No 5. spent the majority of the day in a chair or bed? Yes No 6. felt more weak or tired? Yes No 7. needed more help with daily functions (walking, bathing, eating, dressing) Yes No 8. noticeably lost weight? Yes No 9. experienced shortness of breath, even when resting? Yes No 10. had a provider state life expectancy is limited? Yes No Name(Required) Email(Required) Zip Code(Required) Phone #(Required) Δ
