Palliative Care Needs Assessment Quiz

1

Have you been diagnosed with one or more serious illnesses, such as:* This field is required.- Cancer - Congestive heart failure (CHF) - Chronic obstructive pulmonary disease (COPD), emphysema, or other lung disease - Kidney failure - Liver failure - Neurological conditions (such as ALS or Parkinson’s disease) - Dementia

Yes

No

2

Are you experiencing symptoms that limit your daily activities or affect your quality of life? For example:* This field is required.- Pain or discomfort - Shortness of breath - Fatigue - Anxiety or depression - Loss of appetite - Nausea - Constipation

Yes

No

3

Have you or a loved one experienced any of the following:* This field is required.- Challenging side effects from medical treatments - Difficulty eating due to illness - Frequent visits to the emergency room - Three or more hospital stays within the past 12 months for similar symptoms

Yes

No

4

Do you or your loved one need support with:* This field is required.- Understanding what to expect moving forward - Finding available programs and resources - Making decisions about treatment options - Aligning medical care with personal goals and values - Weighing the benefits and risks of treatments (such as dialysis, surgery, or additional cancer care)

Yes

No

5

Do you or your loved one need help with:* This field is required.- Managing the stress of a serious illness - Emotional support - Spiritual or religious support - Talking with family about your condition and what matters most to you

Yes

No

6

Would you like us to contact you with more information about palliative care services?* This field is required.

Yes

No

7

Your Name

First Name

Last Name

8

Email Address

example@example.com

9

Phone Number

Please enter a valid phone number.