Hospice Assessment | Silverado Hospice

When is it the right time to talk about hospice? Please take a moment to answer a few questions so one of our hospice professionals can assist you.

Location*

First Name*

Last Name*

Phone Number

Email Address*

Please select the yes/no options to let us know if any of the following have been experienced:

A doctor has provided a limited life expectancy

YesNo

Visits to ER, hospital and urgent care have increased in regularity in recent months

YesNo

Contacting the doctor with questions on a more regular basis

YesNo

Additional assistance is needed for activities of daily living (eating, bathing, dressing, etc.)

YesNo

Number of falls has increased in recent months

YesNo

Please select the yes/no options to let us know if any of the following have been experienced:

Mobility has decreased leading to more time in bed or sitting

YesNo

General feeling of tiredness and weakness has grown

YesNo

Noticeable weight loss

YesNo

Breathing is more difficult, even when at rest

YesNo

Pain medication in increasing doses is required for comfort

YesNo

Please provide any additional information that may help our hospice team understand your needs.

Message (max 750 characters)

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