"*" indicates required fieldsPatient DemographicsPatient Name* First Last Phone*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Directions to houseSpecifics to help assist volunteersEligibilityAge*Date of Birth*Gender Identity*Service currently received* Medical Hospice Palliative Care Neither Palliative or Medical HospiceIf not on a medical hospice or palliative care program, answer the following three questions.1. Have you/the patient been hospitalized in the past six months? Yes NoIf yes, how many admissions have there been? 2. Have there been any changes in how much you’re able to do day to day? Yes NoIf yes, what changes have you experienced?3. Has there been noticeable or unintentional weight loss or significant decrease in appetite? Yes NoIf yes, what have you noticed?Clothes fitting looser, pounds lost, changes in eating habits, etc.Name of Medical Palliative or Hospice Organization*If neither list N/APalliative, Hospice, or Life Limiting Diagnosis*DNR?* Yes No UnsurePOLST Form?* Yes No UnsureMedical Limitations Uses walker/cane Wheelchair Bedbound Hearing Impaired Visually Impaired Cognitively Impaired OtherIf other, please explain.Spiritual Practice (if identified)ServicesVolunteer Services Requested* Companionship Respite Evensong Singers Reiki Life Stories (audio recording) Pet Therapy OtherAdditional InformationPrimary Care ProviderPrimary Care Provider and PracticeCaregivers/ContactsPrimary Contact* First Last Relationship*Phone*In home?* Yes NoAdditional Caregiver/ContactTitle or RelationshipIn home? Yes NoAdditional Caregiver/ContactRelationshipIn home? Yes NoReferral InformationReferring Agency*If not an agency, enter n/aPhone*Referred by:*Title or Relationship*Email*
