Move Beyond Your Grief

Grief Assessment

Please rate yourself using the key below in each of these areas:





  Not at all   Somewhat   Very Much
Physical Reactions
Fatigue 1 2 3 4 5
Nausea 1 2 3 4 5
Insomnia 1 2 3 4 5
Dizziness 1 2 3 4 5
Headaches 1 2 3 4 5
Loss of Appetite 1 2 3 4 5
Rapid Heart Rate 1 2 3 4 5
Over-all tenseness 1 2 3 4 5
Cognitive Reactions
Confusion 1 2 3 4 5
Hyper-vigilance 1 2 3 4 5
Memory problems 1 2 3 4 5
Lack of concentration 1 2 3 4 5
Poor decision making 1 2 3 4 5
Poor problem solving 1 2 3 4 5
Easily reminded of the event 1 2 3 4 5
Intrusive thoughts and images 1 2 3 4 5
Emotional Reactions
Fear 1 2 3 4 5
Guilt 1 2 3 4 5
Anger 1 2 3 4 5
Denial 1 2 3 4 5
Anxiety 1 2 3 4 5
Sadness 1 2 3 4 5
Shame 1 2 3 4 5
Depression 1 2 3 4 5
Self-blame 1 2 3 4 5
Longing 1 2 3 4 5
Behavioral Reactions
Agitation 1 2 3 4 5
Emotional outbursts 1 2 3 4 5
Avoidance of others 1 2 3 4 5
Impaired work performance 1 2 3 4 5
Increased need to keep busy 1 2 3 4 5
Increased or decreased appetite 1 2 3 4 5
Increase alcohol consumption 1 2 3 4 5
Increased interpersonal conflicts 1 2 3 4 5
Decreased interests in usual activities 1 2 3 4 5
Excessive sleeping 1 2 3 4 5

When Grief overwhelms me it feels like

The one thing I wish would change is

My biggest fear is

What I would like to have happen is


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Thank you for your time, energy, and honesty.