Name
*
First Name
Last Name
Date
*
-
Year
-
Month
Day
Date
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
Several Days
More than half the days
Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5.Poor appetite or overeating
6.
Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8.
Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself
Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
Several Days
More than half the days
Nearly every day
1. Feeling nervous, anxious, or on edge
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid as if something awful might happen
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1) Have you wished you were dead or wished you could go to sleep and not wake up?
Please Select
Yes
No
2) Have you had any actual thoughts of killing yourself?
Please Select
Yes
No
If yes to 2, answer questions 3, 4, 5 and 6. If no to 2, go directly to question 6.
3) Have you been thinking about how you might do this?
Please Select
Yes
No
(e.g., “I thought about taking an overdose but I never made a specific plan as to when, where or how I would actually do it ... and I would never go through with it.”)
4) Have you had these thoughts and had some intention of acting on them?
Please Select
Yes
No
As opposed to “I have thoughts but I definitely will not do anything about them.”
5) Have you started to work out or worked out the details of how you would kill yourself?
Please Select
Yes
No
6) Do you intend to carry out this plan?
Please Select
Yes
No
If yes to question 5
7) Have you ever done anything, started to do anything, or prepared to do any thing to end your life?
Please Select
Yes
No
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
If yes to question 7, was this within the last 3 months?
Please Select
Yes
No
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