Spiritual Assessing Caregiver Recipient Form

You may use the form online and print your answers as you would any web page, or you may download a MSWord copy or a PDF file copy. We only ask that you not change the form without our permission. For permission e-mail us.

General Questions

1. Gender □ Male □ Female
2. Race? □ White/Caucasian □ Black/Afro-American □ Native American Asian,
□ Pacific Islander □ Hispanic □ Multi-racial
3. Marital status? □ Married □ Single, never married □ Separated □ Divorced
□ Widow, Widower

4. Highest level of education? □ Not much as high school □ High School or GED
□ College Graduate □ Graduate degree(s)
5. Military service? □ Yes □ No Active combat? □ Yes □ No

6. How often do you attend services? □ Seldom □ Weekly □ More than once a week
7. Would you attend more often if transportation was provided? □ Yes □ No
8. How often do you pray? □ Seldom □ Weekly □ Daily □ Frequently (twice a day or
            more)
9. How often do you read the Bible? □ Seldom □ Weekly □ Daily
10. How often do you listen to religious programs on radio of TV? □ Seldom □ Weekly
            □ Daily
11. How much is your religion a source of strength and comfort to you? □ Not at all □ A slight
            bit □ Quite a bit □ A great deal
12. My faith involves all of my life: Do you □ Strongly disagree □ Disagree □ Agree
        □ Strongly Agree?
13. Do you think about death? □ Never □ Sometimes □ Often □ Very Often
14. Do you feel God/Life has treated you unfairly? □ Never □ Sometimes □ Often □ Very
            Often
15. Do you feel despair or hopeless? □ Never □ Sometimes □ Often □ Very Often
16. Do you feel sad or experience grief? □ Never □ Sometimes □ Often □ Very Often
17. Do you feel guilty over past behaviors? □ Never □ Sometimes □ Often □ Very Often
18. Do you feel life has no meaning or purpose? □ Never □ Sometimes □ Often □ Very
            Often
19. Do you worry about doubts/disbelief in God? □ Never □ Sometimes □ Often □ Very
            Often
20. Does anger or resentment block your peace of mind? □ Never □ Sometimes □ Often
            □ Very Often

21. What are your wishes regarding life-sustaining treatment if you have a terminal illness?
            □ Allow me to die
            □ Prolong my life
            □ I don’t know/don’t want to say
            □ I don’t understand the question

22. How do you want “terminal condition” to be interpreted?
            □ Includes permanently unconscious
            □ Does not include permanently unconscious
        □ I don’t know/don’t want to say
            □ I don’t understand the question
23. Do you want to receive artificially provided food and fluids if you are in a terminal condition?
            □ Yes—I wish to receive both food and fluids
            □ No—I do not wish to receive either food or fluids
        □ I don’t know/don’t want to say
            □ I don’t understand the question
24. Do you wish to talk with a minister or counselor? □ Yes □ No
25. If there is anything you wish to say about yourself, or this assessment, please write it here.