Self-Assessment Questionnaire

Self-Assessment
Questionnaire

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If you are interested in how you can receive support through our Transitional Care Program, please complete this brief questionnaire:

Name

Email

Phone

Address

I am over the age of 65.

Yes No None

I have family members and/or friends who assist with my care during the day and night.

Yes No None

I would like to know the available options to consider the possibility of moving into an assisted living residence.

Yes No, I already have chosen the assisted living facility that I would like to move to None

I hope to remain in the comforts of my home when I need to receive healthcare support.

Yes No None

I have been spending most of the day in a chair or in my bed.

Yes No None

I find it difficult to take 20 steps without the assistance of a walker, wheelchair or cane.

Yes No None

I have started to need help with one or more of the following (bathing, dressing, eating, walking, getting out of bed).

Yes No None

I am uninterested in eating full meals and have had a reduced appetite in the past 3 months.

Yes No None

I received one or multiple chronic diagnoses from my physician that significantly impacts my well-being.

Yes No None

I am often drowsy or confused for long periods of time during the day or night.

Yes No None

I have lost a significant amount of weight in the past 6 months.

Yes No None

I am in an increasing amount of pain from symptoms that my doctor has discussed with me, but I am still unsure what to do to be comfortable.

Yes No None

I have visited the ER or been hospitalized 2+ times over the past 3 months.

Yes No None

I am happiest when…

The person responsible for making decisions for me/my loved one if we are able to join hospice care is…

I would like to receive my choices for the best recommended transitional care plan by

Phone Email In-home visit By mail None

Time's up

By clicking submit, you consent to us following up with you by phone or e-mail regarding your self-assessment and whether you are appropriate and eligible for hospice care. If you decide you do not want to be contacted further, please e-mail us at intake@comfortcarehospice.us.

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