(205) 523-0101
Reset Questionnaire
Complete the questions below as they apply to your loved one.
1. Does he/she have an illness that causes pain or trouble breathing?
Yes
No
2. Has he/she had a change in their ability to perform daily activities such as walking, eating, bathing, dressing, or going to the bathroom?
Yes
No
3. Does he/she have a hard time keeping their balance while standing or walking?
Yes
No
4. Has he/she fallen recently and had a hard time getting up?
Yes
No
5. Has he/she been admitted to the hospital or had to go to the emergency room more than once in the past 6 months?
Yes
No
6. Has he/she had frequent infections such as urinary tract infections or pneumonia in the past 6 months?
Yes
No
7. Does he/she have an illness that they are getting treatment for but it is no longer working?
Yes
No
8. Do the side effects of treatment outweigh the benefits?
Yes
No
9. Would he/she rather be cared for by professionals in the comfort of their own home instead of doctors' offices and hospitals?
Yes
No
10. Would you or other family members benefit from additional help and support?
Yes
No
Name
This field is for validation purposes and should be left unchanged.
When is the right time for hospice?
I want answers for:
Myself
A Loved One
