Grief Assessment
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Question 1 of 56
1. Question
Physical Reactions
Please rate your experience in each of these areas:
Fatigue
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Not At All Very Much
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Question 2 of 56
2. Question
Nausea
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Not At All Very Much
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Question 3 of 56
3. Question
Insomnia
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Not At All Very Much
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Question 4 of 56
4. Question
Dizziness
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Not At All Very Much
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Question 5 of 56
5. Question
Headaches
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Not At All Very Much
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Question 6 of 56
6. Question
Loss of appetite
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Not At All Very Much
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Question 7 of 56
7. Question
Rapid heart rate
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Not At All Very Much
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Question 8 of 56
8. Question
Overall Tenseness
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Not At All Very Much
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Question 9 of 56
9. Question
Cognitive Reactions
Please rate your experience in each of these areas:
Confusion
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Not At All Very Much
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Question 10 of 56
10. Question
Hypervigilance
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Not At All Very Much
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Question 11 of 56
11. Question
Memory problems
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Not At All Very Much
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Question 12 of 56
12. Question
Lack of concentration
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Not At All Very Much
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Question 13 of 56
13. Question
Poor decision making
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Not At All Very Much
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Question 14 of 56
14. Question
Poor problem solving
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Not At All Very Much
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Question 15 of 56
15. Question
Easily reminded of the event
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Not At All Very Much
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Question 16 of 56
16. Question
Intrusive thoughts and images
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Not At All Very Much
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Question 17 of 56
17. Question
Emotional Reactions
Please rate your experience in each of these areas:
Fear
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Not At All Very Much
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-
Question 18 of 56
18. Question
Guilt
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Not At All Very Much
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Question 19 of 56
19. Question
Anger
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Not At All Very Much
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Question 20 of 56
20. Question
Denial
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Not At All Very Much
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Question 21 of 56
21. Question
Anxiety
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Not At All Very Much
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Question 22 of 56
22. Question
Sadness
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Not At All Very Much
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Question 23 of 56
23. Question
Shame
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Not At All Very Much
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Question 24 of 56
24. Question
Depression
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Not At All Very Much
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Question 25 of 56
25. Question
Self-blame
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Not At All Very Much
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Question 26 of 56
26. Question
Longing
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Not At All Very Much
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Question 27 of 56
27. Question
Behavioral Reactions
Please rate your experience in each of these areas:
Agitation
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Not At All Very Much
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-
Question 28 of 56
28. Question
Emotional outbursts
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Not At All Very Much
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Question 29 of 56
29. Question
Avoidance of others
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Not At All Very Much
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Question 30 of 56
30. Question
Impaired work performance
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Not At All Very Much
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Question 31 of 56
31. Question
Increased need to keep busy
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Not At All Very Much
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Question 32 of 56
32. Question
Increased or decreased appetite
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Not At All Very Much
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Question 33 of 56
33. Question
Increased alcohol consumption
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Not At All Very Much
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Question 34 of 56
34. Question
Increased interpersonal conflicts
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Not At All Very Much
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Question 35 of 56
35. Question
Decreased interests in usual activities
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Not At All Very Much
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Question 36 of 56
36. Question
Excessive sleeping
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Not At All Very Much
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Question 37 of 56
37. Question
Beliefs About Grief
Please rate your experience in each of these beliefs:
1. My heart will always have this wound so I will never be happy again.
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Not At All Very Much
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Question 38 of 56
38. Question
2. My grief and mourning should be focused on my departed. Self-care is selfish.
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Not At All Very Much
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Question 39 of 56
39. Question
3. I must do grief alone because no one can possibly understand the pain I am going through.
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Not At All Very Much
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Question 40 of 56
40. Question
4. I will never be happy again.
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Not At All Very Much
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Question 41 of 56
41. Question
5. I would never see a grief therapist/guide. It would do no good.
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Not At All Very Much
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Question 42 of 56
42. Question
6. My departed is gone. If I stop longing for them, I may forget him/her.
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Not At All Very Much
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Question 43 of 56
43. Question
7. If I move forward, that is dishonoring my departed.
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Not At All Very Much
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Question 44 of 56
44. Question
8. Loss is a part of life. Grief is a natural consequence of loss.
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Not At All Very Much
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Question 45 of 56
45. Question
9. I am not broken. I am broken open to feel emotions, heal through the guidance of the body and discover Integrated Wellbeing.
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Not At All Very Much
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Question 46 of 56
46. Question
10. Grief is a gateway to growth.
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Not At All Very Much
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Question 47 of 56
47. Question
Diving Deep
Please complete or answer in your own words:
1. When grief overwhelms me it feels like…
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 48 of 56
48. Question
2. The one thing I wish would change is…
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 49 of 56
49. Question
3. My biggest fear is…
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 50 of 56
50. Question
4. What I would like to have happen is…
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 51 of 56
51. Question
5. What is working to release your grief?
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 52 of 56
52. Question
6. Is there a ray of hope in all of this? If so, what is it?
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 53 of 56
53. Question
7. What is not working to release your grief?
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 54 of 56
54. Question
8. Where is grief in your body?
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 55 of 56
55. Question
9. What would you like to have happen as an outcome of us working together?
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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Question 56 of 56
56. Question
10. By when?
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This response will be awarded full points automatically, but it can be reviewed and adjusted after submission.
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