About this template
This Palliative Care Assessment Form is designed for healthcare providers, social workers, and clinical staff to systematically evaluate the care needs of patients with severe or life-limiting illnesses. Conducting a thorough initial assessment is crucial for establishing an effective, patient-centered palliative environment that prioritizes comfort, symptom management, and clear communication.
This comprehensive template captures essential patient demographics, insurance and pension details, emergency contact persons, and legal directives such as powers of attorney or advance health directives. It also records referral sources, complete medical history, current signs and symptoms, medication lists, and a detailed body system review including pain management and daily living challenges. Additionally, it logs the credentials of the completing staff member to ensure accurate clinical record-keeping.
Built to streamline clinical workflows, this Google Form template eliminates cumbersome paperwork and organizes patient intake data securely in one place. Healthcare teams can customize the questions to align with their facility's protocols, ensuring seamless transitions of care and better support for both patients and their families.
Key features
- Collect complete patient demographics and insurance details in one intake.
- Document emergency contacts and legal health directives securely.
- Record detailed medical history, symptoms, and current medications.
- Streamline clinical evaluations with organized sections for body system reviews.
- Track referral sources and completing staff information for compliance.
Use cases
Initial clinical intake for newly referred palliative care patients.
Comprehensive health and symptom reviews conducted by hospice nurses.
Multi-disciplinary care planning meetings requiring detailed patient ā¦
Multi-disciplinary care planning meetings requiring detailed patient history.
Documenting advanced directives and primary contact preferences for cā¦
Documenting advanced directives and primary contact preferences for care facilities.
What this form collects
- Full Name (Short answer)Enter the patient's first and last name.
- Date of Birth (Date)Provide the patient's date of birth.
- Gender (Multiple choice)Select the patient's gender.
- Phone Number (Short answer)Primary contact number for the patient or household.
- Email Address (Short answer)Patient or family contact email.
- Residential Address (Paragraph)Enter the patient's current home address or facility name.
- Medicare Card Number (Short answer)Enter the patient's Medicare number if applicable.
- Insurance Policy Number (Short answer)Provide private insurance or supplemental policy numbers.
- Health Care / Pension Card Number (Short answer)Enter card numbers if applicable.
- Contact Person 1 Full Name (Short answer)Primary family member or proxy contact name.
- Contact Person 1 Phone Number (Short answer)Primary contact phone number.
- Contact Person 1 Relationship (Short answer)Relationship to the patient (e.g., Spouse, Adult Child).
- Contact Person 2 Full Name (Short answer)Secondary contact person name, if applicable.
- Contact Person 2 Phone Number (Short answer)Secondary contact phone number.
- Contact Person 2 Relationship (Short answer)Relationship to the patient.
- Power of Attorney Status (Multiple choice)Indicate the status of medical/financial power of attorney.
- Advance Health Directive Status (Multiple choice)Does the patient have an advance care directive in place?
- Will Status (Multiple choice)Status of a legal will or testament.
- Referral Date (Date)Date the referral was received.
- Type of Referral (Multiple choice)Select the referral classification.
- Referral Source & Referrer Name (Short answer)Name of the referring physician, hospital, or organization.
- Referrer Contact Details (Paragraph)Phone number, email, and address of the referrer.
- Medical Diagnosis (Paragraph)Primary terminal or severe illness diagnosis.
- Date of Diagnosis (Date)Approximate date when the primary diagnosis was confirmed.
- Medical & Family History (Paragraph)Summarize past medical history and significant family illnesses.
- Current Signs and Symptoms (Paragraph)List primary symptoms currently experienced by the patient.
- Allergies Details (Paragraph)List any known drug, food, or environmental allergies.
- Current Medications List (Paragraph)List current medications, dosages, and frequencies.
- Pain Type and Location (Paragraph)Describe the nature of any pain (e.g., sharp, dull, intermittent) and specific body locations.
- Vital Signs (Short answer)Record blood pressure, heart rate, oxygen saturation, and temperature if measured.
- Weight (lbs) and Height (cm) (Short answer)Enter recent weight and height measurements.
- Sleep Disturbances (Multiple choice)Assess trouble sleeping status.
- Nausea and Vomiting Status (Multiple choice)Indicate severity of nausea or vomiting.
- Breathing Problems Status (Multiple choice)Assess shortness of breath or respiratory distress.
- Appetite Problems Status (Multiple choice)Assess appetite and nutritional intake issues.
- Detailed Body System Review (Paragraph)Provide any additional observations regarding neurological, cardiovascular, gastrointestinal, or integumentary systems.
- Completing Staff Full Name (Short answer)Enter your first and last name.
- Job Position / Title (Short answer)Your clinical role (e.g., Registered Nurse, Social Worker, Physician).
- Institution Name (Short answer)Name of hospital, hospice, or care facility.
- Staff Phone Number & Email (Short answer)Your professional contact details for follow-up inquiries.
- Signature & Date Signed (Paragraph)Please paste a link to your signed document (Google Drive, Dropbox, etc.) or type your full legal name as an electronic signature confirmation.
FAQ
How can I customize this form for my healthcare facility?
You can instantly copy this template to your Google Drive via Doc2Form and add, remove, or edit any questions to match your organization's specific clinical intake requirements.
Is this form template free to use?
Yes, this template is entirely free to convert into a Google Form using Doc2Form.
Can patients or family members fill this out remotely?
Absolutely. You can share the Google Form link via email or messaging, allowing families to complete the intake information securely from home before an admission meeting.
Where is the submitted patient data stored?
All form submissions are automatically saved to a secure Google Sheet linked directly to your Google Form, giving your care team instant access to the data.
Can I include fields for staff signatures and sign-off?
Yes, the template includes designated fields for the completing staff member's name, title, institution, and date of completion to maintain accurate medical records.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.