Palliative Care Needs Assessment

Palliative Care Needs Assessment — Form Fields

This healthcare template includes 7 fields. Assess physical, emotional, and support needs of patients receiving palliative or end-of-life care. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Current pain level (1 = none, 5 = unbearable) (rating, required)
• Which symptoms are currently most distressing? (select all that apply) (checkboxes, required) — options: Pain, Fatigue, Nausea or vomiting, Shortness of breath, Anxiety or depression, Loss of appetite
• Does the patient have an advance directive or living will in place? (multiple choice, required) — options: Yes, No, In progress
• Preferred Care Setting (dropdown selection, required) — options: Home, Hospice facility, Hospital, Nursing home or long-term care
• What additional support services are needed? (select all that apply) (checkboxes, optional) — options: Chaplaincy or spiritual care, Social work, Bereavement support for family, Home health aide, None at this time
• Additional notes on patient goals or family concerns (long text, optional)