Questionnaire PHYSICAL NEEDS Pain Management 1. Are you currently struggling with pain? * Yes No 2. Are your current pain medications providing adequate relief? * Yes No Symptom Control 3. Do you have any issues with breathing (e.g., shortness of breath, wheezing)? * Yes No 4. Are you experiencing nausea, vomiting, or loss of appetite? * Yes No 5. Do you have trouble sleeping? * Yes No Mobility 6. Are you able to move around independently? * Yes No 7. Do you already have Medical Equipment (e.g. Walker or Wheelchair, etc)? * Yes No Nutrition and Hydration 8. Are you able to eat and drink as usual? * Yes No 9. Do you have any difficulties swallowing? * Yes No 10. Do you feel you are eating or drinking less than before? * Yes No Hygiene and Personal Care 11. Are you able to bathe and take care of personal hygiene independently? * Yes No 12. Do you require assistance with dressing or toileting? * Yes No EMOTIONAL AND PSYCHOLOGICAL NEEDS Emotional Well-Being 13. Do you often feel anxious or worried? * Yes No 14. Do you feel depressed or hopeless? * Yes No 15. Have you had any thoughts of hurting yourself? * Yes No 16. Do you feel you have adequate emotional support from family, friends, or caregivers? * Yes No 17. Have you been able to express your fears or concerns to someone you trust? Yes No 18. Are there any activities or hobbies you would like to continue or start? * Yes No 19. Do you have the opportunity to engage in social interactions? * Yes No Cognitive Function 20. Do you experience confusion or difficulty concentrating? * Yes No 21. Have you noticed any changes in your memory? * Yes No Future Planning 22. Have you made end-of-life decisions (e.g., advanced directives, living will)? * Yes No 23. Do you need assistance with understanding or making these decisions? * Yes No SPIRITUAL NEEDS Spiritual Well-Being 24. Do you have any spiritual or religious beliefs that are important to you? * Yes No 25. Would you like to speak with a spiritual advisor or clergy member? * Yes No OTHER 26. Have you made arrangements for your financial affairs? * Yes No 27. Do you need help with legal matters related to your care? * Yes No 28. Would you prefer to receive end-of-life care at home instead of in inpatient/hospice? * Yes No 29. Would you prefer to receive end-of-life care in the hospital/with hospice instead of at home? * Yes No 30. Have you discussed your end-of-life wishes with your family (e.g. burial, cremation, etc)? * Yes No Thank you for submitting the Evermore Compassion Questionnaire. We will compile a list of resources based on your answers.
