Patient InformationPatient Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Your Relationship to the Patient:(Required)SelfSpouse / PartnerChildSiblingFriendOtherIf Other, What is your relationshipThe following are some of the common signs and symptoms we consider, but this is not a complete list. It's not necessary to experience all of these - every individual's needs are circumstances are different, and we take the whole picture into account when determining eligibility. Diagnosed with a life-limiting illness (e.q., cancer, heart failure, COPD, dementia, Alzheimer's etc.) Advised by a physician that life expectancy may be six months or less Frequent hospitalizations or ER visits in the past 6 months Noticeable decline in ability to perform daily activities (bathing, dressing, walking, etc.) Weight loss or loss of appetite Increased fatigue, sleeping, or need for assistance Desire to stop curative treatments and focus on comfort Currently enrolled in palliative care On oxygen or using medical equipment at home Progressive decline despite medical treatment Increased confusion, memory loss, or cognitive decline Recurring infections (e.g., pneumonia, urinary tract infections, sepsis) Difficulty swallowing or frequent choking episodes Shortness of breath at rest or with minimal activity Uncontrolled pain, nausea, or other distressing symptoms Spending most of the day in bed or chair-bound Withdrawal from social interaction or loss of interest in usual activities Changes in mental alertness or periods of unresponsiveness Primary Diagnosis (If Known)Current Living SituationWhere is the patient currently living? At home Assisted living facility Skilled nursing facility Independent living facility (Senior apartment) Hospital Other If Other, Where?Your Contact InformationYour Full Name First Last PhoneEmail Additional Notes or ConcernsBy submitting this form, you agree to be contacted by Solace Hospice Care. All information is kept strictly confidential.
