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Home > Grief in Pieces Support Group Outcome Measures

Please fill this form out

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?

Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed, or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead or of hurting yourself in some way

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

Feeling nervous, anxious or on edge
Not being able to stop or control worrying
Worrying to much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

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

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Below several grief reactions are listed. Please indicate how often you have experienced each reaction in the past month in response to the death of your loved on.

1 2 3 4 5
Never Rarely Sometimes Frecuently Always

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