Admissions

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.