Good Samaritan Hospice - Roanoke, Virginia

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PHYSICIAN'S LINK:

Welcome to the Hospice Appropriateness Test
Please fill out the simple questionnaire below. When you click "Show me my results!" we will calculate your medical appropriateness for hospice based on your answers. At that time you will be able to print out your results or contact us. We have trained staff ready to assist you in any way possible. If you are filling this out for a loved one, please substitute the words "your loved one" for "you" in the questions below. All questions are completely optional. However, to get the most accurate results, please answer as many as you can.
1. Has your doctor told you that you have a serious chronic or terminal illness?
Yes No
2. How much weight have you unintentionally lost in the past month?
No weight loss 1-3 pounds 4-6 pounds More than 6 pounds
3. Have you experienced an infection, such as pneumonia or urinary tract infection in the past 3 months?
Yes No
4. Have you been hospitalized or seen in the emergency room in the past 3 months?
Yes No
5. Do you experience shortness of breath while at rest or sitting?
Yes No
6. What level of assistance with personal care (such as bathing or going to the bathroom) do you need?
Total care Some assistance No assistance - completely independent
7. Which of the following diseases do you have? (check all that apply)
Lung disease Heart disease Kidney disease Cancer Dementia (such as Alzheimer’s disease) Stroke Diabetes Liver disease HIV / AIDS Other
8. How old are you?

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