Promoting Excellence : PEACE - Patient Information Worksheet

University of Chicago: PEACE - Patient Information Worksheet

A two-part intake form used at the PEACE Palliative Care Clinic for patients suffering from dementia or other complex illnesses.

Clinical Care Tools - Clinical Assessment

Palliative Excellence in Alzheimer's Care Efforts (PEACE)
University of Chicago Medical Center
Section of Geriatrics (MC 6098)
5841 South Maryland Ave.
Chicago, IL 60637

Gavin W. Hougham, Research Director
[email protected]

Greg A. Sachs, Chief, Section of Geriatrics
[email protected]

How the grantee used this instrument:
This intake form was designed specifically for the patient with complex illnesses and was used to summarize clinical and functional information from which to make recommendations.

quality of life, symptom assessment, care plan, health status

To use this tool:
You may print and copy this tool for your own use from this site. Please credit source.

Adapted for the PEACE project by Deon Cox-Haley and Lisa Maillard.

To view this tool:
Left click on the download link to view the PDF document in your Web browser. Right-click on the download link to save the document to your computer.
pdf PDF 88 KB / 2 pages (Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.)

Posted September 2004

University of Chicago: PEACE overview page

# UCP12, type:clinical_assessment

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying people and their families. Visit for more resources.

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