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Hospice of Lubbock
Hospice of Lubbock
About Us
About Us
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Bereavement Support
Is Hospice the Answer?
Contact Us
Give Now
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Hospice of Lubbock
Hospice of Lubbock
About Us
Bereavement Support
Is Hospice the Answer?
Contact Us
Give Now
Is Hospice the Answer?
Answer this questionnaire to see whether hospice might be the right fit for you or a loved one.
Have you or a loved one...
Been hospitalized or gone to the ER several times in the past 6 months?
Yes
No
Been making more frequent phone calls to your physicians?
Yes
No
Started taking medication to lessen physical pain?
Yes
No
Started spending most of the day in a chair or bed?
Yes
No
Fallen several times over the past 6 months?
Yes
No
Started needing help with one of the following? (Bathing, dressing, eating, getting out of bed, walking)
Yes
No
Started feeling weaker or feel tired?
Yes
No
Experienced weight loss, making clothes noticeably looser?
Yes
No
Noticed a shortness of breath, even while resting?
Yes
No
Been told by a doctor that life expectancy is limited?
Yes
No
First Name
*
Last Name
*
Email Address
*
Phone
999-999-9999
Hospice Candidate's ZIP Code
*