Qualify for Hospice and Home Health Care in Utah

Please take a few minutes and answer these simple questions to help us determine if you qualify for home health care or hospice in Utah.

Personal Information

Evaluation

• Had a hard time breathing, even while resting? Yes No
• Been calling physicians more often? Yes No
• Felt weaker or more tired? Yes No
• Started losing weight unexpectedly? Yes No
• Fallen multiple times within the past six months? Yes No
• Needed assistance with two or more of the following activities: Yes No

• Getting out of bed
• Dressing
• Walking
• Bathing
• Eating

• Started resting in a chair or bed most of the day? Yes No
• Increased medication to decrease physical pain? Yes No
• Been admitted to the hospital or emergency room multiple times in the past six months? Yes No
• Been told by a doctor there is a limited life expectancy? Yes No