Grief Self-Care Checklist Form
Use this checklist to reflect on your self-care practices and emotional well-being as you navigate grief. All responses are private and intended for your personal insight.
How are you feeling today?
*
Calm
Sad
Angry
Anxious
Numb
Other
Which self-care practices have you engaged in today? (Select all that apply)
Ate a nourishing meal
Took a walk or exercised
Talked to a friend or family member
Practiced mindfulness or meditation
Journaling or creative activity
Rested or napped
Other
How supported do you feel by those around you?
*
Not at all supported
1
2
3
4
Very supported
5
1 is Not at all supported, 5 is Very supported
How well have you been sleeping recently?
*
Very well
Somewhat well
Not well
Having trouble sleeping
How would you rate your energy level today?
*
1
2
3
4
5
What is your current appetite like?
*
Normal
Reduced
Increased
No appetite
Have you found moments of comfort or peace recently?
*
Yes, often
Sometimes
Rarely
Not at all
How comfortable are you with expressing your emotions?
*
Not comfortable
1
2
3
4
Very comfortable
5
1 is Not comfortable, 5 is Very comfortable
Do you feel able to ask for help when you need it?
*
Yes, always
Sometimes
Rarely
No, never
Is there anything else you would like to note about your self-care or feelings today?
Submit
Should be Empty: