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Palliative Care Needs Assessment - Free Healthcare Template | ZenBuild | ZenBuild

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Palliative Care Needs Assessment

Assess physical, emotional, and support needs of patients receiving palliative or end-of-life care.

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Palliative Care Needs Assessment

Assess physical, emotional, and support needs of patients receiving palliative or end-of-life care.

Patient Name*

Current pain level (1 = none, 5 = unbearable)*

Which symptoms are currently most distressing? (select all that apply)*

PainFatigueNausea or vomitingShortness of breathAnxiety or depressionLoss of appetite

Does the patient have an advance directive or living will in place?*

YesNoIn progress

Preferred Care Setting*

What additional support services are needed? (select all that apply)

Chaplaincy or spiritual careSocial workBereavement support for familyHome health aideNone at this time

Additional notes on patient goals or family concerns

Template Details

CategoryHealthcare

IndustryHealthcare

Fields7

Uses0

Views0

healthcarepalliative-careassessmentend-of-lifesupport