Visiting Nurse Association of Southeast Missouri

Online Assessment Questionnaire

Are you currently being treated by a doctor for an illness or injury?	Yes	No
Have all treatments for your illness been stopped even though you have not recovered?	Yes	No
Has your doctor told you that you have 6 months or less to live?	Yes	No
Do you want help with housekeeping tasks, laundry or shopping?	Yes	No
Do you need someone to stay with you for 4 or more hours at a time?	Yes	No
Does your illness, injury, or disability prevent you from leaving your home without help?	Yes	No