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Do you or a loved one have any of these diseases? Choose all that apply.

 Cancer (Progressive/Advanced/Recurrent)
 Advanced Lung Disease (for instance, COPD and dependent on oxygen)
 Stroke (with decreased activity level, mainly in chair or bed)
 End stage kidney disease
 Advanced Heart Disease (for instance, heart failure with increased symptoms or unable to carry on activities without symptoms)
 Other life-limiting illness

Do you or a loved one have liver disease, kidney disease, lung disease, heart disease, or another complicating condition in addition to above?


What is your level of mobility? Choose one answer.

Fully active, able to carry on all pre-disease activities without restriction
 Restricted in physically strenuous activity and able to carry out light work
 Capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours
 Capable of only limited self-care; confined to bed or chair more than 50% of waking hours
 Completely disabled. Cannot carry on self-care. Totally confined to bed or chair

Do any of the following items apply? Choose as many as apply.

 You are not a candidate for curative therapy
 Has a life-limiting illness and chooses not to have life prolonging therapy
 Has unacceptable level of pain lasting > 24 hours and that is related to chronic, progressive illness as in question 1
 Has uncontrolled symptoms (i.e. nausea, vomiting)
 Has more than one visit to the emergency room for the same diagnosis in last 30 days
 Has more than one hospital admission for the same diagnosis in last 30 days
 Has hospital length of stay greater than 10 days without any progress
 Has hospital stay in the intensive care unit greater than 10 days
 Is in the hospital intensive care unit with poor prognosis