Questionnaire - Longleaf Hospice & Palliative Care

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Care Options
Volunteer
About Us
News
Contact Us
Free Consultation

770-939-9179

Care Questionnaire

Find out if hospice or palliative care are right for you.

Please check any answer is applicable. Then, at the end of the survey, provide your contact information and one of our certified nurses will reach out to you.

Do you have one or more serious illnesses such as:

Cancer Congestive heart failure (CHF) Chronic obstructive pulmonary disease (COPD), emphysema, lung disease Kidney failure Liver failure Neurological diseases (e.g., ALS, Parkinson's) Dementia

Do you have symptoms that make it difficult to be as active as you would like to be, or impact your quality of life, such as:

Pain or discomfort Shortness of breath Fatigue Anxiety Depression Lack of appetite Nausea Constipation

Have you, or someone close to you, experienced the following:

Difficult side effects from treatment Eating problems due to a serious illness Frequent emergency room visits Three or more admissions to the hospital within 12 months, and with the same symptoms

Do you, or someone close to you, need help with:

Knowing what to expect Knowing what programs and resources are available Making medical decisions about treatment choices/options Matching your goals and values to your medical care Understanding the pros and cons (benefits/burdens) of treatments (e.g., dialysis, additional cancer treatments, surgery, etc.)

Do you, or someone close to you, need help with:

Coping with the stress of a serious illness Emotional support Spiritual or religious support Talking with your family about your illness and what is important to you

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Looking to talk to a representative or just need to get a hold of us? Let us know how we can help!

770-939-9179

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COMMON CONDITIONS

Heart Disease
Stroke
Renal Failure
Cancer

CARE OPTIONS

Palliative Care
Routine Hospice Care
Grief Support
Inpatient Hospice Care

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