Hospice Eligibility Assessment Questionnaire Form
Complete this assessment to help determine hospice eligibility. Please answer each question based on the individual's current condition.
Primary diagnosis related to hospice consideration
*
Please Select
Cancer
Heart disease
Lung disease
Neurological disorder
Dementia
Other
Has there been a significant decline in functional status over the past 6 months?
*
Yes
No
Unsure
Current ability to perform daily activities
*
Rows
Independent
Needs Assistance
Dependent
Bathing
1
2
3
Dressing
4
5
6
Feeding
7
8
9
Mobility
10
11
12
Frequency of hospitalizations or ER visits in the past 6 months
*
None
1-2 times
3 or more times
Unintentional weight loss in the past 6 months
*
No significant weight loss
5-10% body weight
More than 10% body weight
Unsure
Current symptom burden (rate the severity)
*
Rows
None
Mild
Moderate
Severe
Pain
13
14
15
16
Shortness of breath
17
18
19
20
Fatigue
21
22
23
24
Nausea
25
26
27
28
Does the individual have an advanced directive or care preferences documented?
*
Yes
No
Unsure
Additional comments or relevant information (optional)
Submit Assessment
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