Patient Referral

Take the quiz:

Is it time for hospice?

Answer these questions to determine if hospice care could help in your situation. Dealing with a serious, life-limiting illness is not easy. Crossroads can help by providing symptom management and support for both the family and caregivers.

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Is it time for hospice?

Answer these questions to determine if hospice care could help in your situation. Dealing with a serious, life-limiting illness is not easy. Crossroads can help by providing symptom management and support for both the family and caregivers.

1. Have you been diagnosed with a serious, life-limiting illness? These include (but are not limited to):

  • AIDS
  • Alzheimer's Disease
  • Cancer
  • Cardiopulmonary Disease
  • Cerebral Vascular Accident/Stroke
  • Liver Disease
  • Neurological Conditions (Dementia, Parkinson’s, MS, ALS, Huntington’s Disease)
  • Renal Disease
Yes
No

2. Has there been a recent change in your condition? Some examples might include:

  • Progressive weight loss
  • Several falls in the past six months
  • Shortness of breath, even when resting
  • Spending most of the day confined to bed or a chair
Yes
No

3. Have you found yourself needing more medical support?

  • Are you calling your doctor more?
  • Have you started or increased pain medication?
  • Have you visited the ER or been hospitalized three or more times for the same symptoms in the past six months?
Yes
No

4. Have you started to need more help to perform daily activities? These include:

  • Bathing
  • Dressing
  • Eating
  • Walking
  • Getting out of bed
Yes
No

5. Has your physician given you a prognosis of six months or less to live if the disease progression runs its normal course?

Yes
No

Please select an answer

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