Email What type of supportive services have you been receiving since your loss occurred? (select all that apply) * Select All That Apply Individual Counseling Other online support group Local support group Medication Grief workshops/retreats Self-care Family/Friends Other (please list): Other services: * Patient Health Questionnaire (PHQ-9)
The Patient Health Questionnaire-9 is a self-administered diagnostic instrument for depression, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day).
Over the last two weeks, how often have you been bothered by any of the following problems:
1. Little interest or pleasure in doing things? * 2. Feeling down, depressed, or hopeless? * 3. Trouble falling or staying asleep, or sleeping too much? * 4. Feeling tired or having little energy? * 5. Poor appetite or overeating? * 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down * 7. Trouble concentrating on things, such as reading the newspaper or watching television? * 8. Moving or speaking so slowly that other people could have noticed? * 9. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual? * 10. Thoughts that you would be better off dead, or of hurting yourself in some way? * Grief-related Avoidance Questionnaire (GRAQ)
This is a 15-item questionnaire that asks the patient to rate the degree of avoidance of specific situations related to bereavement. It is important to ask very specific questions about avoidance because otherwise it is easy for the patient to forget what they are avoiding.
Often individuals who have lost a close friend or family member find it very painful to do certain things that remind them of the loss. Below are some situations and activities that are commonly affected. We are asking you to rate each item below by telling us how often you avoid each of these situations. Please rate these items, based on your behavior since the loss.
1. Do you avoid visiting the final place of rest (gravesite, urn, etc.) or memorial site? * 2. Do you avoid places that are associated with the death (for example, hospitals, funeral homes or other places that remind you of the death)? * 3. Do you avoid looking at photographs of the person who died? * 4. Do you find yourself trying not to think about the person who died? * 5. Do you avoid talking about the person who died with family members or friends? * 6. Do you avoid contact with personal belongings of the person who died or is it hard to go through their things? * 7. Do you avoid rooms or places that you associate with the person who died? * 8. Do you avoid activities around your home that are associated with the person who died? (for example, things like eating meals in the dining room, carrying out home improvements that were planned by the person who died, or would have pleased the person, watching television shows that were favorites of the person who died) * 9. Do you avoid activities outside your home that are associated with the person who died? (For example, things like taking a walk they used to take, going to certain restaurants they used to visit, attending religious services in a church or synagogue the person who died frequented) * 10. Do you avoid activities with family members that are associated with the person who died (for example, things like participating in family gatherings)? * 11. Do you avoid social activities with friends that are associated with the person who died (for example, things like accepting dinner invitations, engaging in recreational activities such as watching movies or attending sports events)? * 12. Do you avoid social activities with couples or other groups that provoke feelings of being “odd man out” or feelings of intense longing for the person who died? * 13. Do you avoid going to funerals? * 14. Do you avoid visiting with ill people? * 15. Do you avoid talking with others about their painful losses? *