Who are you completing this assessment for?

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Please note, this calculator was created for people using and needing home care. Would you like to continue with this calculator?

Plex:

This question is not about gender identity, but rather physiological sex.

What is your age?

What was the pleted?

Has a doctor and/or another health care professional told you that you have one or more of the following diseases or chronic health conditions?

Has a doctor and/or another health care professional told you that you have less than 6 months to live?

Has a doctor and/or another health care professional told you that you have less than 6 months to live?

Have you had any difficulty with the following tasks in the past week?

How much difficulty did you have with those tasks in the past week?

Have you had any difficulty with the following tasks in the past week?

Has your ability to carry out these tasks gotten worse over the past 3 months?

Has your ability to make decisions worsened over the last 90 days?

Example: when to get up or have meals, which clothes to wear, or what activities to do

Have you experienced any of the following symptoms or conditions in the past 3 days?

Have you experienced any of the following symptoms or conditions in the past 3 days?

Have you experienced any of the following symptoms or conditions in the past 3 days?

Have you been prescribed or are you currently receiving any of the following treatments?

Have you been scheduled for or begun treatment?

In the past 3 months, how many times were you hospitalized?

example: admitted and stayed in a hospital overnight

In the past 3 months, how many times did you seek care in an emergency department?