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Hospice Questionnaire Mobile App

If you or someone you love is facing a serious, life-limiting illness for the first time and YOU don't know where to turn, hospice may help. Please complete the Hospice Questionnaire mobile app to learn whether hospice could be right for you or a loved one. A GoCanvas account can be specified as being HIPAA compliant. By turning on HIPAA compliance, a number of features that most of users find desirable will be disabled to meet HIPAA Standards. Individual apps in the GoCanvas Application Store can easily be made HIPAA Compliant. If you have any questions or need assistance you can contact our Sales team to help you at Sales@GoCanvas.com. If you would like to enable HIPAA on your GoCanvas account please follow the instructions below: 1. Log onto your Account 2. Click “My Account” in the top right corner of the screen 3. Click “Customize” on the left 4. The third option is for HIPAA Compliance, click “Edit” on the right 5. Check the “Enable HIPAA Compliance” box and select “Save”

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  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Hospice Questionnaire Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

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    If you or someone you love is facing a serious, life-limiting illness for the first time and YOU ...

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    Have you noticed any of the following?

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    An unexplained weight loss over 3-6 months?

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    Shortness of breath with minimal exertion?

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    Recurrent chest pain that is not responsive to medical management?

  • Ico checkbox

    Inability to take care of daily needs such as toileting, walking without risk of a fall, feeding ...

  • Ico checkbox

    Loss of memory and/or inability to communicate consistently more than 6 intelligible words?

  • Ico checkbox

    Been told by a physician that life expectancy is less than 6 months?

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    Had to move to a facility that cares for the elderly or infirmed?

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    Multiple recent hospitalizations?

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    No longer wanting to continue dialysis?

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    Cancer that is not responding to treatment?

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    Liver disease such that fluid builds up the abdomen?

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    If you answered yes to more than one of these questions, you may qualify for hospice.

  • ...and More!

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