Grief in Pieces Support Group Outcome Measures

Full Name

Network ID

Please copy and paste. This is a combination of letters and numbers provided by your facilitator. It looks like this: 0064J00000JdBoe

Group ID

Please copy and paste. This is a combination of letters and numbers provided by your facilitator. It looks like this: 0064J00000JdBoe

Over the last week, how often have you been bothered by any of the following problems?

Feeling nervous, anxious or on edge

0 - Not all all

1 - Several days

2 - More than half the days

3 - Nearly every day

Not being able to stop or control worrying

0 - Not all all

1 - Several days

2 - More than half the days

3 - Nearly every day

Feeling down, depressed, or hopeless

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

Little interest or pleasure in doing things

0 - Not at all

1 - Several days

2 - More than half the days

3 - Nearly every day

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity. This assessment is not intended to be a diagnosis. If you are concerned about your results in any way, please speak with a qualified health professional

0	1	2	3	4	5	6	7	8
Not at all		Slightly		Definitely		Markedly		Very severely

Because of my problem, my ability to work is impaired. ‘0’means ‘not at all impaired and ‘8 ’means very severely impaired to the point I can't work

Please enter a number from 0 to 8.

Because of my problem my home management (cleaning, tidying, shopping, cooking, looking after home or children, paying bills) is impaired.

Please enter a number from 0 to 8.

Because of my problem my social leisure activities (with other peoplee.g.parties, bars, clubs, outings, visits,dating, home entertaining) are impaired.

Please enter a number from 0 to 8.

Because of my problem, my private leisure activities (done alone, such as reading,gardening, collecting, sewing, walking alone) are impaired

Please enter a number from 0 to 8.

Because of my problem, my ability to form and maintain close relationships with others, including those I live with,is impaired

Please enter a number from 0 to 8.