1. Do you feel jealous when you think about them dating someone else?
A. Yes, I feel very jealous
B. Yes, I feel a little jealous
C. No I don’t feel jealous at all
2. Are you looking to date someone else?
A. No, not yet
B. No, but I’m not opposed to the idea
C. Yes, I’m actively looking
3. Do you start crying for no reason?
A. Yes
B. Not sure
C. No
4. If they asked you out again, would you say yes?
A. Definitely
B. Not sure
C. Um, no, never again
5. Did you see yourself being in the relationship for a very long time?
A. Yes
B. Kind of
C. No
6. Do you think about your ex?
A. Yes, I can’t seem to stop
B. I think about them sometimes
C. I don't think about them
7. Have you actively tried moving on?
A. No, I’m bad at it
B. Yes, I think I’m getting the hang of it
C. I’m pretty good at moving on
8. Have you been feeling depressed lately?
A. Yes
B. Not sure
C. No
9. Does it hurt you every time you see them?
A. Yes, a lot
B. Yes, it hurts a bit
C. No, I don’t feel anything
10. Do you find yourself thinking about how they made you feel?
A. Yes, very often
B. Yes, sometimes
C. No, not really
