Prolonged Grief Disorder (PG – 13) ©

 

 

 

Holly G. Prigerson, Ph.D., Paul K. Maciejewski, Ph.D.

 

 

 

 

 

PART I INSTRUCTIONS: FOR EACH ITEM, PLACE A CHECK MARK TO INDICATE YOUR ANSWER.

1.  In the past month, how often have you felt yourself longing or yearning for the person you lost?

   _____ 1= Not at all

   _____ 2 = At least once

   _____ 3 = At least once a week

   _____ 4 = At least once a day

   _____ 5 = Several times a day

2.  In the past month, how often have you had intense feelings of emotional pain, sorrow, or pangs of grief related to the lost relationship?

   _____ 1= Not at all

   _____ 2 = At least once

   _____ 3 = At least once a week

   _____ 4 = At least once a day

   _____ 5 = Several times a day

 

3.  For questions 1 or 2 above, have you experienced either of these symptoms at least daily and after 6 months have elapsed since the loss?

   _____ No

   _____ Yes

 

4.  In the past month, how often have you tried to avoid reminders that the person you lost is gone?

   _____ 1= Not at all

   _____ 2 = At least once

   _____ 3 = At least once a week

   _____ 4 = At least once a day

   _____ 5 = Several times a day

 

5.  In the past month, how often have you felt stunned, shocked, or dazed by your loss?

   _____ 1= Not at all

   _____ 2 = At least once

   _____ 3 = At least once a week

   _____ 4 = At least once a day

   _____ 5 = Several times a day  

 

       

 

PART II INSTRUCTIONS: FOR EACH ITEM, PLEASE INDICATE HOW YOU CURRENTLY FEEL.  CIRCLE THE NUMBER TO THE RIGHT TO INDICATE YOUR ANSWER.

 

 

 

6. Do you feel confused about your role in life or feel like you don’t know who you are (i.e., feeling that a part of yourself has died)?

1

2

3

4

5

 

7. Have you had trouble accepting the loss?

1

2

3

4

5

 

8. Has it been hard for you to trust others since your loss?

1

2

3

4

5

 

9. Do you feel bitter over your loss?

1

2

3

4

5

 

10. Do you feel that moving on (e.g., making new friends, pursuing new interests) would be difficult for you now?

1

2

3

4

5

 

11. Do you feel emotionally numb since your loss?

1

2

3

4

5

 

12. Do you feel that life is unfulfilling, empty, or meaningless since your loss?

1

2

3

4

5

 

 

 

 

 

PART III INSTRUCTIONS: FOR EACH ITEM, PLACE A CHECK MARK TO INDICATE YOUR ANSWER.

13. Have you experienced a significant reduction in social, occupational, or other important areas of functioning (e.g., domestic responsibilities)?

   _____ No      _____ Yes