HOSPICE Needs Assessment

2900 North Street suite 100

Beaumont, Texas 77702

Voice: 409.832.4582

Fax: 409.832.6345

Toll Free: 800.550.7476


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HOSPICE Needs Assessment

	Been hospitalized or to the emergency room several times in the past six months?
	Been making more frequent phone calls to your physicians?
	Started taking medication to lessen physical pain?
	Started spending most of the day in a chair or bed?
	Fallen several times over the past six months?
	Started needing help from others with:
	Bathing
	Dressing
	Eating
	Cooking
	Getting out of bed
	Walking
	Started feeling weaker or more tired?
	Experienced weight loss so that clothes are noticeably looser?
	Noticed a shortness of breath, even while resting?
	Been told by a doctor that life expectancy is limited?

If you answered "yes" to four or more of these questions, then you or your loved one could be eligible for hospice. Hospice can help manage the physical, emotional, and spiritual needs of the patient and support the needs of the family as they deal with issues related to their loved one's terminal illness. For more information about Hospice Of Texas, simply complete and submit the form below. A member of the Hospice Of Texas team will contact you as soon as possible.

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Patient's First Name:

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Hospice and Palliative Care