Medicare Evaluation Tool | Alzheimer’s & Dementia Alzheimer's & Dementia - MED EVAL TOOLS Diagnosis: DementiaPhysician Name*Phone Number*Patient Name*Patient InformationMedicare requires documentation of need for hospice through prognostic data. Please supply that below:Please confirm terminal dx:*Decline in functional status as evidenced by:*Check all that apply: Inability to ambulate without assistance Inability to bathe without assistance Inability to dress without assistance No consistently meaningful verbal communication: stereotypical phrases only or the ability to speak is limited to 6 or fewer intelligible words Urinary & fecal incontinence, intermittent or constant FAST score:AvailableUnavailableScore:7654321Comorbid conditions of a severity to warrant medical treatment (within the last year):Check all that apply: Aspiration pneumonia Decubitus ulcers Unintentional weight loss = or > 10% or serum albumin < 2.5 gm/dl. Pyelonephritis or other UTI Fever, recurrent after antibiotics None of the above Other*Please specify (or mark field N/A): Please respond YES or NO to the statements in this section:I support hospice care for this patient.*YesNoI will be patient’s attending physician.*YesNoI have discussed hospice with patient/loved ones.*YesNoI have discussed terminal diagnosis when it becomes necessary.*YesNoI will sign death certificate when it becomes necessary.*YesNo Based on the information indicated above, the above named patient has a medical prognosis that life expectancy is six (6) months or less, if the terminal illness runs its normal course. Digital Signature*Please enter your name below to serve as your electronic signature.Verification This iframe contains the logic required to handle Ajax powered Gravity Forms.