A. In the past year, have you engaged in the following behaviors to deliberately harm yourself (check all that apply): | ||||
Yes | No | How many times? | Have you gotten medical treatment? | |
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B. If not in the past year, have you EVER done any of the above acts? | ||||
_____ Yes | ||||
_____ No | ||||
If yes to any of the above behaviors in the past year, please complete the questions (C through H) below: | ||||
C. While doing any of the above acts, were you trying to kill yourself? | ||||
_____ Yes | ||||
_____ No | ||||
D. How long did you think about doing the above act(s) before actually doing it? | ||||
_____ None | ||||
_____ "A few minutes" | ||||
_____ <60 minutes | ||||
_____ >1 hour but <24 hours | ||||
_____ More than 1 day but less than a week | ||||
_____ Greater than a week | ||||
E. Did you perform any of the above behaviors while you were taking drugs or alcohol? | ||||
_____ Yes | ||||
_____ No | ||||
F. Did you experience pain during this self-harm? | ||||
_____ Severe pain | ||||
_____ Moderate pain | ||||
_____ Little pain | ||||
_____ No pain | ||||
G. How old were you when you first harmed yourself in this way? __________ | ||||
H. Did you harm yourself for any of the reasons listed below? (check all reasons that apply): 0 = Never; 1 = Rarely; 2 = Some; 3 = Often | ||||
Reasons: | Rating | |||
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Thank you for your responses! |
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