Find out if hospice care is the right decision for you or someone you care for by answering the following questions.

Please note we cannot provide an evaluation unless you provide your name and a means of contact.

Name:

Phone:

E-mail address:

Have you or your loved one…

2.  Had to make more frequent phone calls to your doctor?
     Yes     No

3.  Been taking more medication to control physical pain?
     Yes     No

4.  Been spending most of the day in a chair or bed?
     Yes     No

5.  Fallen several times in the past six months?
     Yes     No

6.  Needed assistance from others with the following:
     Bathing     Getting out of bed    Eating   
     Dressing    Walking

7.  Started feeling weaker or more tired?
     Yes     No

8.  Had a significant weight loss?
     Yes     No

9.  Been short of breath even while resting?
     Yes     No

10.  Been told by a doctor that life expectancy is limited?
     Yes     No

If you would like Big Bend Hospice to provide an evaluation of your or loved one's appropriateness for hospice care, please submit this form now and you will be contacted by a Hospice referral specialist.