1. How much are you having trouble accepting the death of ______________?

Not at all............... 0

Somewhat............... 1

A lot............... 2

2.  How much does your grief still interfere with your life? 

Not at all................. 0

Somewhat ................. 1

A lot..........................2

3. How much are you having images or thoughts of _____________ when s/he 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 him/her, 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