Hospice Intake Form Hospice Intake Form Hospice Intake Form Owner’s/Agent’s Name * Owner’s/Agent’s Name First First Last Last Date * Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Home Phone * Additional Phone Email * Other family members names and ages and other pets * Pet's Name * Date of Birth or Age * Who is your primary veterinarian * Family’s Needs, Beliefs, Goals What brought you to seek our care/ reach out to us? * What do you feel are your biggest challenges and unanswered questions? * What is your experience with hospice care for a pet or person? * What are your beliefs regarding euthanasia or hospice-assisted natural death? * Disease Process and Illness Trajectory Describe how your pet was diagnosed and has been treated so far. How have you been affected by this? * What is your understanding of your pet’s disease and how it may progress? * What medical options have you been offered thus far? * What signs of illness or discomfort are you seeing now? * Quality of Life List 5 things your pet enjoyed prior to the illness * On a scale of 1-10 describe your pet’s current QOL * 1 2 3 4 5 6 7 8 9 10 What are your reasons for giving this number? What can be done to better meet your pet’s QOL needs? * What number would you ascribe to your pet for pain using the BEAP scale? * Treatment Plan Considerations What medications is your pet currently on? * What types of medications do you think your pet would be willing to accept? Please circle all that apply: Pills/ tablets; liquid by mouth; flavored chews; transdermal medications; injectable medications; other What are your financial concerns surrounding the end of life care plan? * What types of complementary treatments would you be interested in? (acupuncture, etc.) * What are your plans in case of emergency or crisis? * What types of diagnostics/ testing would you be interested in pursuing? How does your pet tolerate testing (bloodwork, radiographs)? * What does your pet eat? How much food and water are they drinking? * Do you have any upcoming travel plans? * Environmental Assessment Where does your pet struggle with mobility in the home? Please select all that apply Floors (traction, slippery) Stairs (can they go up/ down without assistance) Thresholds/ Dog doors (can they step through doorways without stumbling) Clutter in main walkways (do they stumble or trip over objects) Food and water bowls (at correct height, good traction) Dog beds (able to get in and out of their bed) Furniture (can they get on/off easily) External pathways (non-slip, free of clutter, not too steep) Car rides (get in and out with ease, settles down once in readily) Captcha Submit If you are human, leave this field blank.
