Home Health Care Assessment Hospice Care Assessment Quiz Step 1 of 8 12% Is your loved one experiencing a serious illness? Yes No Select all that apply: End-State Neurological Disease, such as Alzheimer’s Disease, Dementia, Parkinson’s, Stroke, ALS End-Stage HIV/AIDS Cancer Congestive Heart Failure/ COPD/ Cardiopulmonary Disease End-Stage Liver Disease End-Stage Kidney Disease Significant and Unexpected Weight Loss Other Does your loved one have any of the following symptoms related to that serious illness? Pain Breathing Problems Nausea Confusion No Does your loved one need help with bathing, dressing, getting out of bed and other activities of daily living? Yes No Have disease-directed treatments, like chemotherapy, dialysis or multiple hospitalizations from a chronic disease, become less effective? Yes No What are the priorities for your loved one’s treatment plan? Seeking curative treatment regardless of side effects or need for hospitalization. Focusing on quality of life and avoiding hospital stays and medication side effects. What type of insurance or benefits does your loved one have? Medicare Medicaid Private Insurance Veterans Administration (VA) Benefits None/Other All Done! See Your Results: Fill out the form to see your results and get our guide, 'Complete Guide to Understanding Home Health', for free!First NameLast NameEmail Are you ready to connect with us about care? Yes No By submitting your information, you agree to receive email and telephone communications from us in accordance with our terms and privacy policy. You can opt out of these communications at any time.
