P.O. Box 13190
Savannah, GA 31416

Informal Hospice Eligibility Questionnaire

You or your loved one may be eligible for hospice care if you check four or more statements. However, your primary physician and our Medical Director will make the final decision regarding eligibility. Please check the following statements as they apply to you or your loved one to see if hospice care may be appropriate.

	I have started feeling more tired and weak.
	I experience shortness of breath, even when resting.
	I spend most of the day in bed or in a chair.
	I have noticed an increased weight loss in the past six months.
	I make frequent phone calls to my physician.
	I take medications to lessen physical pain.
	I have fallen several times in the past six months.
	I have made frequent trips to the emergency room in the past six months.
	I need help from others with important daily activities. (bathing, dressing, eating, cooking, walking, getting out of bed)
	My doctor has told me my life expectancy is limited.

Name

Address

City, State, Zip

Email Address

Phone

If you have checked four or more items on the questionnaire, please call or email our admissions office at 912 629-1088 or email info@hospicesavannah.org.

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P.O. Box 13190 Savannah, GA 31416 - (912)355-2289 - (888) 355-4911