Psychological Autopsy Questionnaire
Please complete this form to provide comprehensive information about the deceased individual and the circumstances surrounding their death. Your responses will help in understanding the psychological and situational factors involved.
Full Name of Deceased
*
First Name
Last Name
Date of Birth of Deceased
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Death
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship of Respondent to Deceased
*
Please Select
Parent
Sibling
Spouse/Partner
Child
Friend
Colleague
Other
Circumstances of Death (please describe briefly)
*
Was there a known history of mental health conditions?
*
Yes
No
Unknown
If yes, please specify the mental health conditions diagnosed (select all that apply)
Depression
Anxiety
Bipolar Disorder
Schizophrenia
Substance Use Disorder
Other
To your knowledge, did the deceased exhibit any of the following behaviors in the last 6 months?
*
Rows
Never
Rarely
Sometimes
Often
Expressed hopelessness
1
2
3
4
Withdrew from social activities
5
6
7
8
Talked about death or suicide
9
10
11
12
Displayed sudden mood changes
13
14
15
16
Engaged in risky behavior
17
18
19
20
Were there any significant life events or stressors in the past year?
*
Relationship breakup/divorce
Job loss/financial difficulties
Bereavement
Legal problems
Physical illness
None known
Other
Did the deceased have a history of substance use?
*
Yes
No
Unknown
To your knowledge, did the deceased ever attempt self-harm or suicide before?
*
Yes
No
Unknown
Please provide any additional information you believe is relevant.
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