Hospice Readiness Questionnaire

Please review the items below to see which apply to you.

  • I make frequent calls to my physician.
  • I have made frequent trips to the emergency room in the past six months.
  • I have started feeling more tired and weak.
  • I have fallen several times in the past six months.
  • I take medicine to lessen physical pain.
  • I spend most of the day in bed or in a chair.
  • I experience shortness of breath, even when resting.
  • I have noticed an increased weight loss in the past six months.
  • I need help from others with important daily activities such as bathing, dressing, eating, cooking, walking and getting out of bed.
  • My health care provider told me I have a life limiting illness.

If four or more items apply to you, speak to your medical provider or call Burke Hospice and Palliative Care at 828-879-1601.