Promoting Excellence : Modified City of Hope Patient Questionnaire and CALL Care Cover Letters

Supportive Care of the Dying: Modified City of Hope Patient Questionnaire and CALL Care Cover Letters

Two questionnaires for the patient enrolled in the CALL Care program assessing experiences in the following areas: physical, emotional, spiritual, health care environment, health care providers, and personal information. Includes an introductory cover letter to the patient.

Clinical Care Tool - Clinical Assessment

Supportive Care of the Dying: A Coalition for Compassionate Care
c/o Providence Health System
4805 NE Glisan Street,2E07
Portland, Oregon 97213
tel: (503) 215-5053
fax: (503) 215-5054

Sylvia McSkimming
e-mail: [email protected]

How the grantee used this instrument:
Used to gather information for assessment of the patient at one month, three months, and every three months thereafter. The first, longer version of the questionnaire was filled out at the time of enrolling in the CALL Care program. The second version is shorter and may be used in subsequent data gathering sessions. Only the first eight questions were mandatory.

symptom assessment, psychosocial assessment, health status, function, patient experience

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

Developed specifically for this project by the project team.

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 95 KB / 12 pages (Viewing PDF files requires downloading and installation of the free Adobe Acrobat Reader.)

Posted October 2004

# SCD03, 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.

Promoting Excellence logo and link to home page