- What is your Religion and/or Spiritual Belief(s)?
- Do you or your family have Spiritual Beliefs that might influence your medical decisions?
- Does your Religion/Spiritual Belief(s) provide comfort or not? If not, are they a source of stress?
- Are you affiliated with one or more religious or spiritual community(s)? If yes, is it/are they supportive?
- Do you have any other spiritual needs that you would like the chaplain and/or someone else to address?
– Adapted from CSI-MEMO Spiritual History (Koenig HG. Spirituality in Patient Care, 2nd Ed. Philadelphia, PA: Templeton Press, 2007)