TO BE COMPLETED BY OFFICE PERSONNEL | ||||
Subject name: | ||||
ID number: | Today's date: (year/month/day) | |||
PLEASE check the box next to the answer which best describes how you feel right now: | ||||
1. I think about this person so much that it's hard for me to do the things I normally do... | ||||
Never | Rarely | Sometimes | Often | Always |
2. Memories of the person who died upset me... | ||||
Never | Rarely | Sometimes | Often | Always |
3. I feel I cannot accept the death of the person who died... | ||||
Never | Rarely | Sometimes | Often | Always |
4. I feel myself longing for the person who died... | ||||
Never | Rarely | Sometimes | Often | Always |
5. I feel drawn to places and things associated with the person who died... | ||||
Never | Rarely | Sometimes | Often | Always |
6. I can't help feeling angry about their death... | ||||
Never | Rarely | Sometimes | Often | Always |
7. I feel disbelief over what happened... | ||||
Never | Rarely | Sometimes | Often | Always |
8. I feel stunned or dazed over what happened... | ||||
Never | Rarely | Sometimes | Often | Always |
9. Ever since they died it is hard for me to trust people... | ||||
Never | Rarely | Sometimes | Often | Always |
10. Ever since they died I feel like I have lost the ability to care about other people or I feel distant from people I care about.. | ||||
Never | Rarely | Sometimes | Often | Always |
11. I have pain in the same area of my body or have some of the same symptoms as the person who died... | ||||
Never | Rarely | Sometimes | Often | Always |
12. I go out of my way to avoid reminders of the person who died... | ||||
Never | Rarely | Sometimes | Often | Always |
13. I feel that life is empty without the person who died... | ||||
Never | Rarely | Sometimes | Often | Always |
14. I hear the voice of the person who died speak to me... | ||||
Never | Rarely | Sometimes | Often | Always |
15. I see the person who died stand before me... | ||||
Never | Rarely | Sometimes | Often | Always |
16. I feel that it is unfair that I should live when this person died... | ||||
Never | Rarely | Sometimes | Often | Always |
17. I feel bitter over this person's death... | ||||
Never | Rarely | Sometimes | Often | Always |
18. I feel envious of others who have not lost someone close... | ||||
Never | Rarely | Sometimes | Often | Always |
19. I feel lonely a great deal of the time ever since they died... | ||||
Never | Rarely | Sometimes | Often | Always |
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