Hospice Quiz (Foundations Hospice)

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Have you been diagnosed with a serious, life-limiting illness?* This field is required.These include (but are not limited to): AIDS • Alzheimer's disease • Cancer • Congestive Heart Failure • Digestive Disease • Heart/Cardiovascular Disease • Kidney Disease • Liver Disease • Renal Disease • Neurological Conditions (Dementia, Parkinson's, MS, ALS, Huntington's Disease, Stroke)

YESNO

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Has there been a recent change in your condition?* This field is required.Some examples may include: • Loss of interest in daily activities • Increasing falls or unsteadiness • Increasing usage of a cane, walker or wheelchair • More difficulty swallowing • Increase in daytime sleeping • Progressive, unintentional weight loss • Uncontrollable disease related pain with current medications • Shortness of breath, even while resting • Deteriorating mental abilities

YESNO

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Have you found yourself needing more medical support?* This field is required.• Are you calling your primary or specialty doctor more frequently? • Have you started new or stronger pain medication? • Are you needing more supplemental oxygen? • Have you had recurrent infections? • Have you visited the ER or been hospitalized three or more times for the same symptoms in the past six months?

YESNO

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Have you started to need more help to perform daily activities? * This field is required.These include: • Bathing • Dressing • Eating • Walking • Getting out of bed

YESNO

5

Would you like to focus on quality of life rather than life-prolonging treatments?* This field is required.

YESNO

6

If your score below is 4 or more it would seem that hospice care could help.

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Would you like to share this information with us?* This field is required.Select yes if you would like to share your contact information with our care team.

YESNO

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Your Name* This field is required.

First Name

Last Name

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Your Phone Number* This field is required.

Please enter a valid phone number.

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Please tell us a little more about your situation.* This field is required.

0/500

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Thank you for sharing your information with us. Hospice is 100% covered by Medicare for all eligible patients and is covered by most Medicaid and commercial insurance plans. Anyone can refer a patient to hospice, and the evaluation is free.

By clicking submit below, you'll be giving us permission to contact you by phone to gather a bit more information on your unique situation.

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Unique ID

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Submitter's Name