First Name*

Last Name*

City*

State*

Zip*

Email*

Months Separated

Dumper/Dumpee/Mutual=>D/E/M

First time FDAS=>Y/N*

I am comfortable telling people I am separated from my love partner.

I am physically and emotionally exhausted from morning until night.

I am constantly thinking of my former love partner.

I feel rejected by many of the friends I had when I was in the love relationship.

I become upset when I think about my former love partner.

I like being the person I am.

I feel like crying because I feel so sad.

I can communicate with my former love partner in a calm and rational manner.

There are many things about my personality I would like to change.

It is easy for me to accept my becoming a single person.

I feel depressed.

I feel emotionally separated from my former love partner.

People would not like me if they got to know me.

I feel comfortable seeing and talking to my former love partner.

I feel like I am an attractive person.

I feel as though I am in a daze and the world doesn't seem real.

I find myself doing things just to please my former love partner.

I feel lonely.

There are many things about my body I would like to change.

I have many plans and goals for the future.

I feel I don't have much sex appeal.

I am relating and interacting in many new ways with people since my separation.

Joining a singles' group would make me feel I was a loser like them.

It is easy for me to organize my daily routine of living.

I find myself making excuses to see and talk to my former love partner.

Because my love relationship failed, I must be a failure.

I feel like unloading my feelings of anger and hurt upon my former love partner.

I feel comfortable being with people.

I have trouble concentrating.

I think of my former love partner as related to me rather than as a separate person.

I feel like an okay person.

I hope my former love partner is feeling as much or more emotional pain than I am.

I have close friends who know and understand me.

I am unable to control my emotions.

I feel capable of building a deep and meaningful love relationship.

I have trouble sleeping.

I easily become angry at my former love partner.

I am afraid to trust people who might become love partners.

Because my love relationship ended, I feel there must be something wrong with me.

I either have no appetite or eat continuously which is unusual for me.

I don't want to accept the fact that our love relationship is ending.

I force myself to eat even though I'm not hungry.

I have given up on my former love partner and I getting back together.

I feel very frightened inside.

It is important that my family, friends, and associates be on my side rather than on my former love partner's side.

I feel uncomfortable even thinking about dating.

I feel capable of living the kind of life I would like to live.

I have noticed my body weight is changing a great deal.

I believe if we try, my love partner and I can save our love relationship.

My abdomen feels empty and hollow.

I have feelings of romantic love for my former love partner.

I can make the decisions I need to because I know and trust my feelings.

I would like to get even with my former love partner for hurting me.

I avoid people even though I want and need friends.

I have really made a mess of my life.

I sigh a lot.

I believe it is best for all concerned to have our love relationship end.

I perform my daily activities in a mechanical and unfeeling manner.

I become upset when I think about my love partner having a love relationship with someone else.

I feel capable of facing and dealing with my problems.

I blame my former love partner for the failure of our love relationship.

I am afraid of becoming sexually involved with another person.

I feel adequate as a fe/male love partner.

It will only be a matter of time until my love partner and I get back together.

I feel detached and removed from activities around me as though I were watching them on a moviescreen.

I would like to continue having a sexual relationship with my former love partner.

Life is somehow passing me by.

I feel comfortable going by myself to a public place such as a movie.

It is good to feel alive again after having felt numb and emotionally dead.

I feel I know and understand myself.

I feel emotionally committed to my former love partner.

I want to be with people but I feel emotionally distant from them.

I am the type of person I would like to have for a friend.

I am afraid of becoming emotionally close to another love partner.

Even on the days when I am feeling good, I may suddenly become sad and start crying.

I can't believe our love relationship is ending.

I become upset when I think about my love partner dating someone else.

I have a normal amount of self-confidence.

People seem to enjoy being with me.

Morally and spiritually, I believe it is wrong for our love relationship to end.

I wake up in the morning feeling there is no good reason to get out of bed.

I find myself daydreaming about all the good times I had with my love partner.

People want to have a love relationship with me because I feel like a lovable person.

I want to hurt my former love partner by letting him/her know how much I hurt emotionally.

I feel comfortable going to social events even though I am single.

I feel guilty about my love relationship ending.

I feel emotionally insecure.

I feel uncomfortable even thinking about having a sexual relationship.

I feel emotionally weak and helpless.

I think about ending my life with suicide.

I understand the reasons why our love relationship did not work out.

I feel comfortable having my friends know our love relationship is ending.

I am angry about the things my former love partner has been doing.

I feel like I am going crazy.

I am unable to perform sexually.

I feel as though I am the only single person in a couples-only society.

I feel like a single person rather than a married person.

I feel my friends look at me as unstable now that I'm separated.

I daydream about being with and talking to my former love partner.

I need to improve my feelings of self-worth about being a wo/man.