Have you been diagnosed with a serious, life-limiting illness? *

Yes

These include (but are not limited to): AIDS • Alzheimer's disease • Cancer • Congestive Heart Failure • Digestive Disease • Heart/Cardiovascular Disease • Kidney Disease • Liver Disease • Renal Disease • Neurological Conditions (Dementia, Parkinson's, MS, ALS, Huntington's Disease, Stroke)

Has there been a recent change in your condition? *

Yes

Some examples may include: • Loss of interest in daily activities • Increasing falls or unsteadiness • Increasing usage of a cane, walker or wheelchair • More difficulty swallowing • Increase in daytime sleeping • Progressive, unintentional weight loss • Uncontrollable disease related pain with current medications • Shortness of breath, even while resting • Deteriorating mental abilities

Have you found yourself needing more medical support? *

Yes

• Are you calling your primary or specialty doctor more frequently?

• Have you started new or stronger pain medication?

• Are you needing more supplemental oxygen?

• Have you had recurrent infections?

• Have you visited the ER or been hospitalized three or more times for the same symptoms in the past six months?

Have you started to need more help to perform daily activities? *

Yes

These include:

• Bathing

• Dressing

• Eating

• Walking

• Getting out of bed

Would you like to focus on quality of life rather than life-prolonging treatments? *

Yes

If your score below is 4 or more it would seem that hospice care could help.

Would you like to share this information with us? *

Yes

Select yes if you would like to share your contact information with our care team.

Full Name *

Phone *

Email *

Please tell us a little more about your situation.