1. I am comfortable telling people I am separated from my love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

2. I am physically and emotionally exhausted from morning until night.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

3. I am constantly thinking of my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

4. I feel rejected by many of the friends I had when I was in the love relationship.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

5. I become upset when I think about my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

6. I like being the person I am.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

7. I feel like crying because I feel so sad.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

8. I can communicate with my former love partner in a calm and rational manner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

9. There are many things about my personality I would like to change.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

10. It is easy for me to accept my becoming a single person.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

11. I feel depressed.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

12. I feel emotionally separated from my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

13. People would not like me if they got to know me.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

14. I feel comfortable seeing and talking to my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

15. I feel like I am an attractive person.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

16. I feel as though I am in a daze and the world doesn’t seem real.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

17. I find myself doing things just to please my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

18. I feel lonely.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

19. There are many things about my body I would like to change.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

20. I have many plans and goals for the future.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

21. I feel I don’t have much sex appeal.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

22. I am relating and interacting in many new ways with people since my separation.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

23. Joining a singles’ group would make me feel I was a loser like them.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

24. It is easy for me to organize my daily routine of living.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

25. I find myself making excuses to see and talk to my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

26. Because my love relationship failed, I must be a failure.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

27. I feel like unloading my feelings of anger and hurt upon my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

28. I feel comfortable being with people.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

29. I have trouble concentrating.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

30. I think of my former love partner as related to me rather than as a separate person.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

31. I feel like an okay person.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

32. I hope my former love partner is feeling as much or more emotional pain than I am.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

33. I have close friends who know and understand me.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

34. I am unable to control my emotions.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

35. I feel capable of building a deep and meaningful love relationship.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

36. I have trouble sleeping.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

37. I easily become angry at my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

38. I am afraid to trust people who might become love partners.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

39. Because my love relationship ended, I feel there must be something wrong with me.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

40. I either have no appetite or eat continuously which is unusual for me.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

41. I don’t want to accept the fact that our love relationship is ending.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

42. I force myself to eat even though I’m not hungry.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

43. I have given up on my former love partner and getting back together.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

44. I feel very frightened inside.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

45. It is important that my family, friends, and associates be on my side rather than on my former love partner’s side.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

46. I feel uncomfortable even thinking about dating.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

47. I feel capable of living the kind of life I would like to live.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

48. I have noticed my body weight is changing a great deal.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

49. I believe if we try, my love partner and I can save our love relationship.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

50. My abdomen feels empty and hollow.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

51. I have feelings of romantic love for my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

52. I can make the decisions I need to because I know and trust my feelings.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

53. I would like to get even with my former love partner for hurting me.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

54. I avoid people even though I want and need friends.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

55. I have really made a mess of my life.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

56. I sigh a lot.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

57. I believe it is best for all concerned to have our love relationship end.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

58. I perform my daily activities in a mechanical and unfeeling manner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

59. I become upset when I think about my love partner having a love relationship with someone else.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

60. I feel capable of facing and dealing with my problems.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

61. I blame my former love partner for the failure of our love relationship.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

62. I am afraid of becoming sexually involved with another person.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

63. I feel adequate as a fe/male love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

64. It will only be a matter of time until my love partner and I get back together.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

65. I feel detached and removed from activities around me as though I were watching them on a movie screen.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

66. I would like to continue having a sexual relationship with my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

67. Life is somehow passing me by.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

68. I feel comfortable going by myself to a public place such as a movie.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

69. It is good to feel alive again after having felt numb and emotionally dead.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

70. I feel I know and understand myself.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

71. I feel emotionally committed to my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

72. I want to be with people but I feel emotionally distant from them.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

73. I am the type of person I would like to have for a friend.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

74. I am afraid of becoming emotionally close to another love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

75. Even on the days when I am feeling good, I may suddenly become sad and start crying.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

76. I can’t believe our love relationship is ending.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

77. I become upset when I think about my love partner dating someone.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

78. I have a normal amount of self-confidence.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

79. People seem to enjoy being with me.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

80. Morally and spiritually, I believe it is wrong for our love relationship to end.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

81. I wake up in the morning feeling there is no good reason to get out of bed.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

82. I find myself daydreaming about all the good times I had with my love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

83. People want to have a love relationship with me because I feel like a lovable person.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

84. I want to hurt my former love partner by letting him/her know how much I hurt emotionally.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

85. I feel comfortable going to social events even though I am single.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

86. I feel guilty about my love relationship ending.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

87. I feel emotionally insecure.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

88. I feel uncomfortable even thinking about having a sexual relationship.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

89. I feel emotionally weak and helpless.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

90. I think about ending my life with suicide.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

91. I understand the reasons why our love relationship did not work out.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

92. I feel comfortable having my friends know our love relationship is ending.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

93. I am angry about the things my former love partner has been doing.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

94. I feel like I am going crazy.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

95. I am unable to perform sexually.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

96. I feel as though I am the only single person in a couples-only society.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

97. I feel like a single person rather than a married person.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

98. I feel my friends look at me as unstable now that I’m separated.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

99. I daydream about being with and talking to my former love partner.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

100. I need to improve my feelings of self-worth about being a woman or a man.
—Almost AlwaysUsuallySometimesSeldomAlmost Never

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