This test is composed of 5 questions. It can be self-administered by patients using the rating scales below or used as a guide for an in-depth conversation between a palliative care interdisciplinary team member and a patient.
1. How hopeful are you feeling?
Not at all hopeful - 0 1 2 3 4 5 6 7 8 9 10 -
Very hopeful
2. Are you feeling fearful or anxious about anything?
Not at all - 0 1 2 3 4 5 6 7 8 9 10 -
Very fearful/anxious
3. Are you feeling connected to your family and/or loved ones?
Not at all - 0 1 2 3 4 5 6 7 8 9 10 -
A great deal
4. Are you involved with a spiritual, faith, or religious community at this time?
Not at all - 0 1 2 3 4 5 6 7 8 9 10 - NA -
A great deal
5. How supportive is your spiritual, faith, or religious community at this time?
Not at all - 0 1 2 3 4 5 6 7 8 9 10 - NA -
A great deal
Please tell us how we might be helpful to you in the spiritual area of your life:
Please share other comments about your illness or injury and health care experience you wish us to know:
See reference for more information.Adapted from Tools and Resources. Center to Advance Palliative Care (CAPC). Spiritual dimension screening. Internet. Available at https://www.capc.org/documents/download/122/ Accessed on October 15, 2021.