Questionnaire

Answer the following questions to determine whether palliative care might be right for you or someone close to you. Remember, you can receive palliative care at any point in your illness.

1. Have you been diagnosed with any of the following diseases:

  • Cancer
  • Chronic obstructive pulmonary disease (COPD), emphysema, lung disease
  • Congestive heart failure (CHF)
  • Dementia
  • Kidney failure
  • Liver failure
  • Neurological diseases (e.g., ALS, Parkinson’s)

2. Is your condition causing side effects that impair your quality of life? If yes, do you have:

  • Anxiety
  • Constipation
  • Depression
  • Fatigue
  • Lack of appetite
  • Nausea
  • Pain or discomfort
  • Shortness of breath

3. Have you had any of the following experiences:

  • A serious illness causing eating issues
  • Visiting the Emergency Room with frequency
  • Quality-of-life imparing side effects from treatment
  • Three or more admissions to the hospital within 12 months with the same symptoms

4. Would you like help with?

  • Managing your expectations
  • Finding out more about available programs and resources
  • Making medical decisions about treatment choices/options
  • Matching your goals and values to your medical care
  • Understanding the pros and cons of treatments

5. Do you, or someone close to you, need assistance with:

  • Coping with the stress of a serious illness
  • Emotional support
  • Spiritual or religious support
  • Talking with your family about your illness and what is important to you

IF YOU ANSWERED “YES” TO ANY OF THESE QUESTIONS, YOU MAY BENEFIT FROM PALLIATIVE CARE. CONTACT A PALLIATIVE CARE TEAM MEMBER FOR MORE INFORMATION.

 

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