Big Spring VA Medical Center
Directions: Please answer the following questions by marking an 'X' in the space above the group of words that best describe you.
1. When talking to people- how often do you mention spiritual or religious things?
[] very often [] often [] not very often [] never
2. How often do you pray?
[] very often [] often [] not very often [] never
3. Do you feel that spiritual and religious beliefs are an important pan of your life?
[] yes [] no
4. Do you feel that it is important to ask yourself how God would feel about it before you make an important decision?
[] yes [] no
5. Would you say that you feel close to God or your higher power in your daily life?
[] yes [] no
6. Do your spiritual or religious beliefs or faith help give meaning for your life?
[] yes [] no
7. How often do you fee! guilty over past behaviors?
[] very often [] often [] not very often [] never
8. How often does anger or resentment block your peace of mind?
[] very often [] often [] not very often [] never
9. How often do you feel sad or experience grief?
[] very often [] often [] not very often [] never
10. How often do you feel despair or hopeless?
[] very often [] often [] not very often [] never
11. How often do you feel that God or life has treated you unfairly?
[] very often [] often [] not very often [] never
12. How often do you worry about your doubts or disbelief in God?
[] very often [] often [] not very often [] never
13. How often do you worry about or fear death?
[] very often [] often [] not very often [] never
L. Dean Thomas
Chief, Chaplain Service
VA Healthcare Network Upstate New York
SPIRITUAL NEEDS ASSESSMENT (short)
1. What is your present religious preference?
2. Is there a change in the medical record needed?
[] Yes: change from:
[] No
3. Home Church:
Pastor:
[]Yes, the patient wishes their pastor contacted:
Phone:
[]No, the patient docs not wish their pastor contacted
[] Not necessary, pastor is aware of admission.
Completing this assessment questionnaire will help us to better understand your spiritual care needs. We believe that faith plays an important role in a person's sense of health and weiiness.
Please take a moment and mark the responses which best describe your experiences and feelings.
4. What is the patient's understanding of reason(s) for admission?
5. How often do you attend church, synagogue, or other religious meetings?
[] - Never
[] - Once per year or less
[] - Few times per year
[] - Few times per month
[] - Once per week
[] - More than once per week
Comments:
6. Do you consider religious or spiritua! beliefs to be important in your life?
[] Yes
[] No
Comments:
7. Does your faith or beliefs influence the way you think about your health or the way you take care of yourself?
[] Yes
[] No
Comments:
8. Would you like to receive any devotional materials while you are hospitalized?
[] Yes
[] No
Comments:
9. Would you like to address any religions or spiritual issues with a chaplain?
[] Yes
[] No
Comments:
PASTORAL CARE PLANS:
The veteran is appropriate to attend chapel services and can benefit from traditional religious and spiritual interventions
[] Yes
[] No
The veteran can benefit from the following pastoral care interventions:
[] Genera! Pastoral Care/Visitation
[] Sacramental ministries or religious rites
[] Grief Process Group
[] Assistance with Advance Directives:
[] Education
[] Documentation
[] Religious or Moral Guidance
[] Other assessment needed
[] Spiritual Injury Assessment
[] Refer for Grief Severity Assessment
[] Other assessment
[] Pastoral Counseling for:
[] Companion support by a Spiritual Care Volunteer