Hospice Eligibility Questionnaire

Have you or your loved one been admitted to the hospital or emergency room multiple times in the past 6 months?

Are you experiencing more frequent infections (e.g., pneumonia, urinary tract infections)?

Have you been calling or visiting your healthcare providers more often?

Have you begun taking new or stronger medications to manage physical pain?

Are you spending most of the day sitting or lying down due to fatigue or weakness?

Have you fallen several times in the past few months?

Are you noticing a decline in mobility or balance?

Do you now need assistance with daily tasks such as bathing, dressing, eating, walking, or getting out of bed?

Have you noticed significant or unintentional weight loss or that your clothes fit looser?

Are you experiencing shortness of breath, even when resting or speaking?

Do you tire easily or feel weaker than before?

Have you noticed a decrease in appetite or difficulty swallowing?

Are you or your loved one struggling to discuss care preferences or end-of-life decisions with your doctor or family?

Do you want to learn more about the comfort, dignity, and support hospice can provide?