1. Do you find yourself only thinking about the reasons you miss the person and forgetting about all of the reasons why it didn’t work out?
A. I always try to remind myself of the full picture
B. I definitely used to, but I am getting better with that
C. Yes, I ALWAYS do that and convince myself I really messed up
2. Do you feel like people are sick of hearing you talk about it over and over?
A. I don’t really talk about it much anymore
B. Sometimes, but I can’t help it
C. Yes, my friends/family/coworkers definitely don’t want to talk about it anymore and think I shouldn’t either
3. Are you currently dating or trying to date?
A. Yes / Not yet, but I have been seriously considering it
B. No, I don’t think I am ready yet
C. I am definitely not ready for that!
4. Have you forgiven the person who is no longer in your life?
A. Yes, I had to let all that anger and resentment go
B. I am working on it
C. No! This is all their fault that I am deeply hurt.
5. Have you recently been experiencing signs of extreme stress, such as headaches, chest pains, body aches, upset stomach, loss of appetite, etc., that are occurring more than usual?
A. No, not that I notice
B. Sometimes, but nothing that is seriously concerning me
C. Yes, frequently
6. Do you find it hard to enjoy the things you once enjoyed doing?
7. What is your current emotional state?
A. It depends on the day; it’s kind of unpredictable
B. I tend to be more emotional than normal since the loss
C. I feel upset all the time and often still cry about the loss/ I feel like I have blocked all my emotions
8. Are there areas of your life that you feel like you have lost control over or unhealthy behaviors from your past that are starting to reappear?
A. Not really; I feel like I still have control
B. Sometimes, but nothing serious
C. Yes, I feel like I have lost control over my actions and decision making
9. Do you ever feel like you can’t stop thinking about the loss and obsessing over where things went wrong, being angry and bitter over the situation, or constantly blaming yourself?
A. I try not to think about it, but sometimes, it takes a toll on my health.
B. Sometimes, but I usually just try to keep myself busy.
C. Yes, often
10. Do you find that you feel exhausted in general, to the point where it affects your ability to function in your everyday life?
A. No, I am emotionally drained sometimes, but nothing that severe
B. I used to feel like that all the time, but it is starting to get better
C. Yes, all of the time