For more information about Excela Health emergency services visit our Emergency Department.

1. Has your loved one (mother, father, spouse, etc.) been diagnosed with any of the following conditions?










2. Has your loved one experienced one of more of the following in the past two to three months?
(Check all that apply)









3. Has your loved one's doctor prescribed any of the following treatments/medications?
(Check all that apply)








4. Is your loved one confused about which medications to take, does he/she have trouble keeping track of the medications or has he/she taken the wrong medication/dosage?






5. Does your loved one have a difficult time with any of the following activities?
(Check all that apply)







6. How hard is it for your loved one to move about safely and/or leave the home?
Choose the statement that describes his/her situation best.




Submit Quiz

Does this apply to you or your loved one (please answer "Yes" or "no")

Expressed the desire to stay at home instead of going back to the hospital for treatment?

Experiencing unacceptable levels of pain?

Recognized an increasing dependence on oxygen throughout the day?

Have unmet emotional and spiritual needs?

Have increased symptoms due to chronic illness?

Need additional assistance with bathing, dressing, feeding, toileting or ambulation?

Spend more time in bed?

Lost weight without trying?

Been told that you or your loved one have a life limiting illness or that life expectancy is lessened?

Submit Quiz