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Assessment:
Think back to the time that you realized that you had lost your good health
and that your old self had died and answer all of these items about your
feelings and actions by indicating whether each item is: Completely True,
Mostly True, Both True and False, Mostly False, or Completely False.
1. After my old self had died, I found it hard to get along with certain
people.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
3. After I lost my old self, I lost interest in my family, friends, and outside
activities.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
6. I couldn't keep up with my normal activities (as per how much my new
condition allowed me to) for the first 3 months after I lost my old self.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
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7. I was angry that I am unable to be the person that I wanted to be before
the old me had died.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Now answer all of the following items by checking how you presently feel
about the death of your old self. Do not look back at Part I.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
5. Even now, it's painful to recall memories of the person who I was.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
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6. I am preoccupied with thoughts (often think) about who I was.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
13. At times, I still feel the need to cry for the loss of my old self.
Completely True , Mostly True , Both True and False , Mostly False , or
Completely False
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