1. The patient’s medical condition is eligible for palliative care. (Helpful tools: GSF Prognostic Indicator Guide; SPICT ™) *

Yes

No

Not Sure

2. The patient (or proxy decision maker if patient is not decisional) is aware of, AND accepts that the palliative care seeks to enhance the quality of life and not intended to cure or prolong life. *

* Please call us to discuss if you are unsure or you still believe we have a role in the patient’s care, even though not all the criteria are met.

Yes

No

Not Sure

3. The patient is not currently served by another charity providing home care, OR will have only one charity home care provider. *

* Please call us to discuss if you are unsure or you still believe we have a role in the patient’s care, even though not all the criteria are met.

Yes

No

Not Sure

Name *

First Name

Last Name

Gender

Male

Female

Date of Birth *

MM

DD

YYYY

Language/Dialect Spoken: *

English

Mandarin

Malay

Tamil

Cantonese

Hokkien

Hainanese

Hakka

Teochew

Others

Religion *

Buddhism

Christianity

Islam

Hinduism

Others

Contact number *

(###)

###

####

Name *

First Name

Last Name

Languages/Dialects spoken *

English

Mandarin

Malay

Tamil

Cantonese

Hokkien

Hainanese

Hakka

Teochew

Others

Contact number *

(###)

###

####

Name of referring doctor *

First Name

Last Name

Contact No

(###)

###

####

Drug Allergy (If yes, plesae specify below) *

No

Yes

Compassionate discharge *

Yes

No