Loss History Questionnaire

Nicole E. Johnson, RN, MBA
Certified Grief Recovery Method® Specialist

First Name

Last Name

Have you experienced any of the following?

Did you ever move or change schools growing up?

Did you ever have a pet die?

Did you graduate from high school? ...from college?

Are your parents divorced?

Did your parent(s) have a substance abuse issue?

Did you grow up with an emotionally or physically absent parent?

Are there long stretches of your childhood you cannot remember?

Have you experienced a major change in finances? (+ or -)

Have you ever quit a job? Have you ever been fired?

Have you ever been married or divorced?

Have you experienced the death of anyone close to you?

Were you physically or sexually abused as a child? ...as an adult?

Have you ever had a miscarriage, stillbirth or fertility issues?

Have you ever been bullied or made to feel inferior in any way?

Do you have a strained or painful relationship with anyone?

Have you ever experienced the loss or use of any part of your body?

Have you experienced a series of accidents or illnesses?

Have you served in the military?

Have you been passed over for a promotion or raise?

Does your spouse work long hours or travel for work?

Have you ever had a relationship end?

Have you been in a long series of unsuccessful relationships?

Have you ever experienced the pain of infidelity?

Have you ever been a caregiver or helped someone recover medically?

Do you have regular thoughts of not feeling good about yourself?

Do you live with FOMO and spend too much time on social media?

Are you living with any unrealized hopes, dreams, or desires?