Hospice & Palliative Care Intake Form
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Hospice & Palliative Care Intake Form
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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.
What's included
- Terminal diagnosis and functional status documentation
- Comprehensive symptom burden and pain assessment
- Advance directive and goals of care documentation
- Caregiver identification and burden screening
- Spiritual, cultural, and psychosocial needs assessment
- Home safety and equipment needs evaluation
- E-signature capture
- Structured medication list with dosage and frequency tracking
Who uses this template
- Hospice agencies providing home, inpatient, and residential care
- Hospital-based palliative care consultation services
- Outpatient palliative care and supportive oncology clinics
- Long-term care facilities with hospice partnerships
All form fields
16 fields across 3 pages. Customize any field after signing up.
How to use the Hospice & Palliative Care Intake Form
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Hospice & Palliative Care Intake Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the Hospice & Palliative Care Intake Form in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 16 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the Hospice & Palliative Care Intake Form HIPAA compliant?
Yes. All Formisoft templates, including the Hospice & Palliative Care Intake Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 16 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The Hospice & Palliative Care Intake Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the Hospice & Palliative Care Intake Form for your practice. Set up in minutes.
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