| Do you currently have worries about yourself? | 1 | 2 | 3 | 4 | 5 |
| Do you currently have worries about your loved one(s)? | 1 | 2 | 3 | 4 | 5 |
| Was it helpful today to look at both your own worries and those of your loved one(s)? | 1 | 2 | 3 | 4 | 5 |
| Will you talk about your worries with health care providers? | 1 | 2 | 3 | 4 | 5 |
| Will you talk about your worries with your family/ friends | 1 | 2 | 3 | 4 | 5 |
| Do you currently have spiritual concerns? | 1 | 2 | 3 | 4 | 5 |
| Did the exercise help you to look at the role spirituality has played in your life? | 1 | 2 | 3 | 4 | 5 |
| Did the exercise help you look at the connection between spirituality and your illness? | 1 | 2 | 3 | 4 | 5 |
| Will you talk to your health care providers about your spiritual needs? | 1 | 2 | 3 | 4 | 5 |
| Will you talk to your family / friends about your spiritual needs? | 1 | 2 | 3 | 4 | 5 |
| Do you currently have Advanced Directives? | 1 | 2 | 3 | 4 | 5 |
| Were the questions on the Vermont worksheet helpful? | 1 | 2 | 3 | 4 | 5 |
| Do you feel you have the information you need to fill out/update your Advance Directives if you wish to do so? | 1 | 2 | 3 | 4 | 5 |
| Will you talk to your health care providers about your Advance Directives? | 1 | 2 | 3 | 4 | 5 |
| Will you talk to your family/friends about your Advance Directives? | 1 | 2 | 3 | 4 | 5 |
| Is communication with your physicians and other health care providers a problem? | 1 | 2 | 3 | 4 | 5 |
| Has the discussion today provided you with more ideas about how to communicate your needs and concerns? | 1 | 2 | 3 | 4 | 5 |
| Will you talk to your health care providers about your communication with them? | 1 | 2 | 3 | 4 | 5 |
| Will you enlist family and friends to help communicate your needs and concerns? | 1 | 2 | 3 | 4 | 5 |