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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