Spiritual Survey
1. How old are you?
18-20
21-29
30-39
40-49
50-59
60 or older
2. In what type of healthcare setting do you currently work ?
Rural
Urban
Other
3. What is your Gender?
Please Select
Male
Female
Other, not listed
4. What is your race?
Please Select
African American/Black
American Indian or Alaska Native
Asian
Latino
Native Hawaiian or other Pacific Islander
White
Multiple races
Other
5. What is you highest level of education?
Please Select
Less than high school degree
High School degree or equivalent (e.g., GED)
Some college but no degree
Associate degree
Bachelor degree
Graduate degree
6. Marital status
Please Select
Married or in a cohabiting relationship
Widowed
Divorced
Separated
Never married
Other
7. Which of the following best describes your personal income?
$0-$9,999
$10,000-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000+
Prefer not to answer
8. Number of years worked in healthcare
0-5
6-10
11-15
16-20
21-25
26-30
More than 30
9. What is your religious affiliation?
Please Select
Jewish
Christian
Islam
Hindu
Buddhism
Atheist
I prefer not to answer
Other
10. On a scale of 1-10 with 1 being the lowest and 10 being the highest, how important are your spirituality to you?
Lowest
1
2
3
4
5
6
7
8
9
Highest
10
1 is Lowest, 10 is Highest
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Perceived Stress Scale
Rows
Never
Almost Never
Sometimes
Fairly Often
Very Often
1. In the last month, how often have you been upset because of something that happened unexpectedly?
1
2
3
4
5
2. In the last month, how often have you felt that you were unable to control the important things in your life?
6
7
8
9
10
3. In the last month, how often have you felt nervous and "stressed"?
11
12
13
14
15
4. In the last month, how often have you felt confident about your ability to handle your personal problems?
16
17
18
19
20
5. In the last month, how often have you felt that things were going your way?
21
22
23
24
25
6. In the last month, how often have you found that you could not cope with all the things that you had to do?
26
27
28
29
30
7. In the last month, how often have you been able to control irritations in your life?
31
32
33
34
35
8. In the last month, how often have you felt that you were on top of things?
36
37
38
39
40
9. In the last month, how often have you been angered because of things that were outside your control?
41
42
43
44
45
10. In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?
46
47
48
49
50
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Spiritual Well-Being Scale
For each of the following statements circle the choice that best indicates the extent of your agreement or disagreement as it describes your personal experience: SA = Strongly Agree, MA = Moderately Agree, A = Agree, D = Disagree, MD = Moderately Disagree, SD = Strongly Disagree
Rows
Strongly Agree
Moderately Agree
Agree
Disagree
Moderately Disagree
Strongly Disagree
SD
1. I don't find much satisfaction in private prayer with God.
51
52
53
54
55
56
57
2. I don't know who I am, where I came from, or where I'm going.
58
59
60
61
62
63
64
3. I believe that God loves me and cares about me.
65
66
67
68
69
70
71
4. I feel that life is a positive experience.
72
73
74
75
76
77
78
5. I believe that God is impersonal and not interested in my daily situations.
79
80
81
82
83
84
85
6. I feel unsettled about my future.
86
87
88
89
90
91
92
7. I have a personally meaningful relationship with God.
93
94
95
96
97
98
99
8. I feel very fulfilled and satisfied with life.
100
101
102
103
104
105
106
9. I don't get much personal strength and support from my God
107
108
109
110
111
112
113
10. I feel a sense of well-being about the direction my life isheaded in.
114
115
116
117
118
119
120
11. I believe that God is concerned about my problems.
121
122
123
124
125
126
127
12. I don't enjoy much about life.
128
129
130
131
132
133
134
13. I don't have a personally satisfying relationship with God.
135
136
137
138
139
140
141
14. I feel good about my future.
142
143
144
145
146
147
148
15. My relationship with God helps me not to feel lonely.
149
150
151
152
153
154
155
16. I feel that life is full of conflict and unhappiness.
156
157
158
159
160
161
162
17. I feel most fulfilled when I'm in close communion with God.
163
164
165
166
167
168
169
18. Life doesn't have much meaning.
170
171
172
173
174
175
176
19. My relation with God contributes to my sense of well-being.
177
178
179
180
181
182
183
20. I believe there is some real purpose for my life.
184
185
186
187
188
189
190
Submit
Should be Empty: