TCHN Checklist Δ Living with a serious illness can be overwhelming. This checklist can help you recognize when it may be time to have a conversation about additional support at home.(Required)Select all that apply in the last 6 months Been hospitalized or visited the ER more than once? Found everyday activities, like getting dressed, becoming more difficult? Felt weaker or more tired than usual? Lost weight without trying? Became short of breath with everyday activities? Needed help bathing, dressing, cooking or just getting around? Had more pain or symptoms that are becoming harder to control? Fallen or became unsteady while walking? Been told your sickness can’t be cured? Had more trouble recovering after sickness or hospital stays? Started thinking more about quality of life? Have been spending more time sitting or lying down? Name(Required) First Last Location(Required) City ZIP / Postal Code Phone(Required)Email(Required) Inquiring on services for(Required) First Last I consent to a member of The Carpenter Health Network contacting me based on this completed form.(Required) I consent Comments(Required)Please provide any additional information about you or your loved one's condition, so we can best assist you.
