Demographic Questionnaire

Directions: Please answer the following questions about your demographic characteristics. The
information will be kept confidential and will only be used to prepare a general profile of study
participants.

1. Age: _________

2. Gender
a. Female b. Male

3. Education
a. Grade School d. Bachelor’s Degree
b. High School e. Master’s
c. Associate Degree f. Doctorate
g. other _______

4. Preferred Racial/Ethnic Identity: _____________

5. Living Arrangements
a. Married c. Widowed
b. Single d. Other
c. Divorced

6. Religion: ________________

7. Work status

Average # of hours per week _______

8. Do you consider yourself a religious person?

a. Not at all c. Very religious
b. Moderately religious d. Other _____

9. Do you consider yourself a spiritual person?

a. Not at all c. Very spiritual
b. Moderately spiritual d. Other

10. Type of Cardiac Illness: _____________________

 Spirituality Scale
Please indicate your level of agreement to the following statements by circling the appropriate
number that corresponds with the answer key.
Key:
1. Strongly Disagree
2. Disagree
3. Mostly disagree
4. Mostly agree
5. Agree
6. Strongly Agree

1. I find meaning in my life experiences. 1 2 3 4 5 6

2 I have a sense of purpose. 1 2 3 4 5 6
3. I am happy about the person I have become. 1 2 3 4 5 6
4. I see the sacredness in everyday life. 1 2 3 4 5 6
5. I meditate to gain access to my inner spirit 1 2 3 4 5 6
6. I live in harmony with nature. 1 2 3 4 5 6
7. I believe there is a connection between all things that I cannot see but can 1 2 3 4 5 6
sense.
8. My life is a process of becoming. 1 2 3 4 5 6
9. I believe in a Higher Power/Universal Intelligence. 1 2 3 4 5 6
10. I believe that all living creatures deserve respect. 1 2 3 4 5 6
11. The earth is sacred. 1 2 3 4 5 6
12. I value maintaining and nurturing my relationships with others. 1 2 3 4 5 6
13. I use silence to get in touch with myself. 1 2 3 4 5 6
14. I believe that nature should be respected. 1 2 3 4 5 6
15. I have a relationship with a Higher Power/Universal Intelligence. 1 2 3 4 5 6
16. My spirituality gives me inner strength. 1 2 3 4 5 6
17. I am able to receive love from others. 1 2 3 4 5 6
18. My faith in a Higher Power/Universal Intelligence helps me cope during 1 2 3 4 5 6
challenges in my life.
19. I strive to correct the excesses in my own lifestyle patterns/practices. 1 2 3 4 5 6
20. I respect the diversity of people. 1 2 3 4 5 6
21. Prayer is an integral part of my spiritual nature. 1 2 3 4 5 6
22. At times, I feel at one with the universe. 1 2 3 4 5 6
23. I often take time to assess my life choices as a way of living my spirituality. 1 2 3 4 5 6

© Copyright, 2003 by C. Delaney

Note: Those interested in using the SS for clinical or research purposes are asked to contact Dr. Colleen
Delaney RN, PhD, AHN-BC Associate Professor, University of Connecticut, 231 Glenbrook Rd, Storrs, CT
06269-2026, Colleen.Delaney@uconn.edu

Spirituality Scale Scoring Sheet

The highest possible score that can be obtained on the 23-item SS is 138 and the lowest, 23. It is theorized that
scores between 23-60 indicated very low levels of spirituality, 61 – 91 indicated low spirituality, 92 – 117 moderate
spirituality, and 118-138 suggested high levels of spirituality

Total SS ____________

Self-Discovery
The range of possible scores on the self-discovery scale was 4-24

Questions :
1 _____
2 _____
3 _____
4______

Total ________ If score < 20 activate Self-Discovery Intervention

Relationships
6-item relationship subscale has a possible scoring range of 6 – 36
Questions:
10 _____
12 _____
14 _____
17 _____
19 _____
20 _____

Total________ If score is < 30 activate Relationship intervention

Eco-Awareness
13-item subscale has a possible range of 13 – 78.
Questions:
5 _____ 9 _____
6 _____ 15 _____
7 _____ 18 _____
8 _____ 21 ______
11 _____
13 _____
16 _____
22 _____
23 _____ Total ________

If score is < 65 activate prayer/environment intervention