Change font size Increase font size  Decrease font size  Default font size
Self Assessment Quiz for Transitions

How would I know when to involve Transitions?

The following self-assessment can help you consider if the time is right to begin receiving care and support from Transitions for you or your loved one.

Check all the statements that apply.
Lately, I need assistance: Getting out of bed
Walking
Preparing Meals
Eating
Getting Dressed
Taking a shower or bath
In addition: I've become weaker and more fatigued.
I'm becoming short of breath, even at rest.
I've lost weight without trying.
I'm tired and I just want to be comfortable.
I don't want any more surgery.
I don't want any more chemotherapy.
I've fallen several times in recent months.
I've been hospitalized or needed emergency care several times in the past year.
The pain medications I take are not working as well as they used to.
I spend a good part of my day lying in bed or just sitting.
I am experiencing swelling.
I am on oxygen most of the time.
I am calling my doctor more often than I used to.
My doctor has said that my life expectancy is limited.
I don't want tubes or IVs to feed me.

How many statements did you check? If you checked four or more, you could benefit from Transitions care. Physical care and resources, emotional and spiritual support, and help for both you and your loved ones are available from Transitions.

Please do not hesitate to contact manager Elena-Marie Ankiewicz at 352-854-5200, or e-mail this form to learn more about how you and your loved one can begin receiving the support you deserve.

Your Name:
Patient's Name:
Phone:
(000-000-0000)
Email:
Diagnosis:
Comments:
Please contact me by: Email    Phone
Be assured that this information is confidential and protected by the federal privacy act.
 
Copyright © 2006 Hospice of Marion County.