Palliative Care Assessment Form
Client Information
Name
First Name
Last Name
Age
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Male
Female
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medicare Card No.
Policy No.
Health Care/Pension Card No.
Contact Person Details
Contact Person 1
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship with the patient
Contact Person 2
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship with the patient
Does these contacts have the power of attorney?
Yes
No
Does the patient have advance health directive?
Yes
No
Does the client have a Will?
Yes
No
Referral Details
Referral Date
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Referral
Please Select
Urgent
Priority
Routine
Source of Referral
Referrer Name
Referrer Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Referrer Email
example@example.com
Referrer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Status
Medical Diagnosis
Date of Diagnosis
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical History
Family History Illnesses
Asthma
Cardiovascular Disease
Diabetes Mellitus
Hypertension
Tuberculosis
Other
Current Signs and Symptoms
Does the patient have allergies? Please list them below:
Please list the current medications the client is taking
Rows
Medication Name
Dose
Frequency
Route
Indication
1
2
3
4
5
6
7
8
Is the patient experiencing pain? If yes, please list what type of pain?
Acute pain
Chronic pain
Neuropathic pain
Nociceptive pain
Radicular pain
Other
Where is the pain in the part of your body?
Vital Signs
Rows
Value
Remarks
Temperature
Blood Pressure
Heart Rate
Respiratory Rate
Weight (lbs)
Height (cm)
Body System Review
Rows
Normal
Not Normal
Remarks
Sensory (Eyes, ears, nose, throat)
1
2
Musculoskeletal (Mobility)
3
4
Integumentary (Rashes, irritation, pale)
5
6
Neurovascular (Paint, seizures, sensation)
7
8
Circulatory (Skin, edema)
9
10
Respiratory (Shortness of breath)
11
12
Dental (Dentures)
13
14
Psychosocial (Hallucinations, delusions)
15
16
Nutrition (Diet, weight change, swallowing)
17
18
Elimination (Constipation, incontinence)
19
20
Does the patient have trouble sleeping?
Yes
No
Does the patient experience nausea and vomiting?
Yes
No
Does the patient have problem in breathing?
Yes
No
Does the patient have appetite problems?
Yes
No
Details of Person Completing this form
Name
First Name
Last Name
Job Position/Title
Institution Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Signature
Date Signed
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: