1. To the best of your memory, at what age were you first aware of death?
   Under the age of 3
   Age 3 to 5
   Age 5 to 10
   Age 10 and up
   Other
   

2. When you were a child, how was death talked about in your family?
   Openly
   As though death were a forbidden subject
   With some discomfort
   Don't remember any talk about death
   Only when necessary, and not in front of children
   

3. Which of the following most influences the way you think about death now?
   Death of someone close
   TV, movies, radio
   Things you have read
   Length of time family members have lived
   Religion
   Funerals
   Own health
   

4. Has religion played an important part in the way you think about death?
   Very important
   Important
   Not very important
   No part at all
   

5. How often do you think about your own death?
   At least once a day
   Often
   Not more than once a year
   Sometimes
   Never or almost never
   Other
   

6. What does death mean to you?
   The end of life
   End of physical life; the spirit lives on
   Endless sleep and peace
   Don't know
   A new beginning, of life after death
   Other
   

7. What thing about your own death bothers you the most?
   I could no longer have any experiences
   I am afraid of what might happen to my body after death
   I am not sure what will happen to me if there is life after death
   I could no longer provide for my family
   My relatives and friends would grieve
   The process of dying might be painful
   Other
   

8. What do you believe causes most deaths?
   Most deaths happen because the person wants to die
   Most deaths happen because of the way the person uses or fails to use things such as tobacco, alcohol, medicines, or seat belts
   Most deaths just happen
   Other
   

9. If your doctor knew that you would die from a disease and had a limited time left to live, would you want the doctor to tell you?
   Yes
   No
   Depends on circumstances
   

10. If it were possible, would you want to know the exact date on which you were going to die?
    Yes
    No
    Other
    
    
    
    

Adapted from an assessment tool from Michael Seago, Medical Innovations, 1994. Reprinted by permission from About.com