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


General information request.
- 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.