| 1. How much are you currently having trouble accepting the death of ______________? | |
| Not at all | 0 |
| Somewhat | 1 |
| A lot | 2 |
| 2. How much does your grief interfere with your life now? | |
| Not at all | 0 |
| Somewhat | 1 |
| A lot | 2 |
| 3. How much are you bothered by images or thoughts of _____________ when they died or other thoughts about the death that really bother you? | |
| Not at all | 0 |
| Somewhat | 1 |
| A lot | 2 |
| 4. Are there things you used to do when ______ was alive that you don't feel comfortable doing anymore, that you avoid? Like going somewhere you went with them, or doing things you used to enjoy together? Or avoiding looking at pictures or talking about _________? How much are you avoiding these things? | |
| Not at all | 0 |
| Somewhat | 1 |
| A lot | 2 |
| 5. How much are you feeling cut off or distant from other people since _________ died, even people you used to be close to like family or friends? | |
| Not at all | 0 |
| Somewhat | 1 |
| A lot | 2 |
| Total: | |
