HOSPICE COMFORT QUESTIONNAIRE (MODIFIED) Date Code# Below are statements that relate to your comfort right now. Six numbers are provided for each question. Please circle the mumber you think most closely matches your feeling. Relate these questions to your comfort af the moment you are answering the questions: Strongly Strongly. Agree Disagree 1. Mybodyis relaxed = 6 5.4 3 2 1 ‘Tight now 2. My breathing is 6 5 4 3 2 1 difficult 3. Theeaetosel 6 5S 4 3 2 1 can depend on when need help 4 Iwonyaboumy 6 5 4 3 2 1 family S Imowlmbvee 6 5 4 3 2 1 6. Thesesuroméings 6 5 4 3 2 1 are pleasant 7. Unvedificuty 6 5 4 3 2 1 ‘esting 8. [feel peaceful 6 5 4 a) 1 9. Isleep soundly 6 5 4 32 1 1O.Tlikebeimghere 96 95 4 302 1 11. Tam nauseated 6 504 32 112. Tamable to. communicate with, my loved ones 13. Lam afraid of ‘what is next 14. [have experienced changes that make ne feel uneasy 15. My mouth and skin feel very dry 16. Lam okay with my personal relationships 17. Lean ise above my pain 18. The mood around hereis depressing 19. This bed makes me hut 20. feel confident spiritually 21. Lfeel good enough to do some things for myself 22. eel hopeless 23. Teel lonely,