Grief/Loss

How much are you having trouble accepting your loss? (death of a loved one, loss of a job, divorce, migration, etc)




How much does your grief interfere with your life now?




How much are you bothered by images or thoughts of a loved one when they died or other thoughts about the death that really bother you?




Are there things that you used to do when this loved one was alive that you don't feel comfortable doing anymore, that you avoid? Such as going somewhere you went with them, or doing things you used to enjoy together? Or avoiding looking at pictures or talking about this person? How much are you avoiding these things?




How much are you feeling cut off or distant from other people you used to be close to like family or friends since this loss occurred?




Over the last two weeks, how often have you had little interest or pleasure in doing things?





Over the last two weeks, have you felt down, depressed, or hopeless?





Over the last two weeks, have you had trouble falling or staying asleep, or sleeping too much?





Over the last two weeks, have you felt tired or having little energy?





Over the last two weeks, have you had a poor appetite or been overeating?





Over the last two weeks, have you felt bad about yourself, or that you are a failure or have let yourself or your family down?





Over the last two weeks, have you had trouble concentrating on things, such as reading the newspaper or watching television?





Over the last two weeks have you moved or spoke so slowly that other people could have noticed? Or so fidgety or restless that you have beeen moving a lot more than usual?





Over the last two weeks, have you had thoughts that you would be better off dead, or thoughts of hurting yourself in some way?





Have you ever been evaluated for mental health disorders in the past?

Are you currently in treatment for a mental health disorder?

What helps you cope with your grief? What makes it worse?

Do you smoke, drink alcohol, use recreational drugs?

Are you currently taking any medications, vitamins, or supplements?

Do you have any allergies?

Would you like to share anything else with your provider through an upload?

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