Spiritual History Assessment

  1. What is your Religion and/or Spiritual Belief(s)?
  2. Do you or your family have Spiritual Beliefs that might influence your medical decisions?
  3. Does your Religion/Spiritual Belief(s) provide comfort or not? If not, are they a source of stress?
  4. Are you affiliated with one or more religious or spiritual community(s)? If yes, is it/are they supportive?
  5. 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)