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The Strathmor Group

Morrison 4C's Spiritual & Emotional Self-Assessment - For Cancer

(Download this form in PDF)

CONFIDENTIAL: Only to those with access to medical records

Name: __________________________________________________

Date: __________________________________________________

Spiritual & Emotional Self-Assessment:

The Four Cs - Cancer, Coping, Comfort, Community

This reflection will help our team serve you better.

Instructions:
a) take your time
b) there are no right or wrong answers
c) check as many boxes as apply to you now
d) please write additional comments if you wish

1) How do you feel about the cancer?

___	o.k.	___	anxious	___	helpless
___	at peace	___	angry	___	depressed
___	hopeful	___	why me?	___	sad
___	uninformed/confused	___	sense of loss	___	betrayed
___	lonely	___	fearful	___	guilty
___	other comments:
_________________________________________________________________________
_________________________________________________________________________

2) How are you coping?

___	just fine	___	avoiding reality	___	loss of meaning
___	good family/friends support	___	stressed	___	financial worries
___	experiencing closer ties	___	no energy	___	anxious about children
___	partner/family not coping	___	fearful	___	not coping well at all
___	other comments:
_________________________________________________________________________
_________________________________________________________________________

3) What are your sources of comfort (strength, hope and support)?

___	family	___	music	___	friends
___	nature walks	___	pets	___	no sources
___	physical activity	___	prayer/meditation	___	religious practices (e.g. worship, scripture, sacraments)
___	self	___	faith		religious practices (e.g. worship, scripture, sacraments)
___	other comments:
_________________________________________________________________________
_________________________________________________________________________

4) Do you have a faith community? (and/or a community of support?)

___	yes	___	none	___	had faith community, not now
___	personal meditation/prayer	___	loss of faith since cancer	___	nature experiences
___	friends, congregation	___	spiritual but not religious	___	hurtful memories of religion
___	support group (e.g. A.A.)	___	religious and spiritual	___
___	other comments:
_________________________________________________________________________
_________________________________________________________________________

Thank you very much for supplying this information. Please ask if you have any questions.

Caring for the Whole Person

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