Hospice Request For Assessment Form

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Hospice is appropriate for patients who require end of life care. Patients have a life expectancy of less than 3 months and a PPS of 50% or less. The patient/family have care needs that cannot be met at home but do not require the care of an acute care facility. Eligibility criteria can be found at www.hospicehalifax.ca

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  • Yes
  • No
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  • Unspecified
  • Home
  • Hospice
  • Hospital - ER
  • Hospital - Other
  • Hospital - PCU
  • Long Term Care
  • Marginal
  • Nursing Home
  • Prison
  • Retirement Home
  • Rooming House
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  • Yes
  • No
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  • No
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  • No
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  • Unspecified
  • Unavailable
  • 1 Week
  • 2 Weeks
  • 3 Weeks
  • 1 Month
  • 2 Months
  • 3 Months
  • 4 Months
  • 5 Months
  • 6 Months
  • 1 Year
  • 2 Years
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