Significant Loss CheckList

This checklist is designed to discover the important losses that people have experienced in their lives.  You are being asked to identify the ones that pertain to you.  Write in your age, at the time the specific loss occured to you.  Leave the line blank if it does not apply to you.

Loss of Person

First Name Relation to you Your Age then
1. Death A
2. Separation A

Body Part

Describe Cause Your Age Then
3. Vitality
4. Limb
5. Sense Organ
6. Other


Describe Cause Your Age Then
07. Ability to Work
08. Love from Family
09. Self Respect
10. Other


Describe Cause Your Age Then
11. Business/Job
12. Home, Property
13. Pet
14. Other