Hospice & Palliative Care Intake Form

The Hospice & Palliative Care Intake Form is designed for hospice agencies and palliative care programs, capturing the holistic assessment data needed to deliver compassionate, person-centered end-of-life care. This template collects patient demographics alongside a thorough clinical assessment including primary terminal diagnosis, prognosis, disease trajectory, functional status (PPS or Karnofsky score), symptom burden assessment covering pain (location, intensity, character, current management), dyspnea, nausea, fatigue, anorexia, constipation, anxiety, depression, delirium, and insomnia. The form documents current medications with attention to appropriateness for the goals of care and potential deprescribing opportunities.

Built for hospice agencies (home, inpatient, and residential), hospital-based palliative care consultation services, palliative care outpatient clinics, and long-term care facilities with hospice partnerships, this form includes sections for advance directive documentation (living will, healthcare power of attorney, POLST/MOLST, DNR/DNI status), goals of care discussion documentation, caregiver assessment (primary caregiver identification, caregiver burden screening, respite needs), psychosocial assessment (emotional coping, grief anticipation, family dynamics), spiritual and cultural care preferences, bereavement risk assessment for surviving family members, home safety evaluation, durable medical equipment needs, and interdisciplinary team referral triggers for social work, chaplaincy, and volunteer services.

All fields are HIPAA-compliant and crafted with sensitivity to the unique needs of patients and families facing serious illness and end of life. The form uses compassionate, dignified language throughout. Pre-visit completion by the patient or caregiver allows the palliative care team to arrive at the initial visit prepared to address the most pressing symptoms and concerns, establish goals of care, and begin building the trusting relationship that is the foundation of excellent end-of-life care.