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.