From: Suicide risk among prisoners in French Guiana: prevalence and predictive factors
In the past month did you: | |||
---|---|---|---|
Item | Question | Answer | Points |
C1 | Suffer any accident? | NO YES | 0 |
IF NO TO C1, SKIP TO C2; IF YES, ASK C1a,: | |||
C1a | Plan or intend to hurt yourself in that accident either passively or actively? | NO YES | 0 |
IF NO TO C1a, SKIP TO C2: IF YES, ASK C1b,: | |||
C1b | Did you intend to die as a result of this accident? | NO YES | 0 |
C2 | Think that you would be better off dead or wish you were dead? | NO YES | 1 |
C3 | Want to harm yourself or to hurt or to injure yourself? | NO YES | 2 |
C4 | Think about suicide? | NO YES | 6 |
IF YES, ASK ABOUT THE INTENSITY AND FREQUENCY OF THE SUICIDAL IDEATION: | |||
Frequency: Occasionally, Often, Very often | |||
Intensity: Mild, Moderate, Severe | |||
Can you control these impulses and state that you will not act on them while in this program? Only score 8 points if response is NO. | NO YES | 8 | |
C5 | Have a suicide plan? | NO YES | 8 |
C6 | Take any active steps to prepare to injure yourself or to prepare for a suicide attempt in which you expected or intended to die? | NO YES | 9 |
C7 | Deliberately injure yourself without intending to kill yourself? | NO YES | 4 |
C8 | Attempt suicide? Hoped to be rescued/survive Expected/intended to die | NO YES | 10 |
In your lifetime: | |||
C9 | Did you ever make a suicide attempt? | NO YES | 4 |
IS AT LEAST 1 OF THE ABOVE (EXCEPT C1) CODED YES? IF YES, ADD THE TOTAL NUMBER OF POINTS FOR THE ANSWERS (C1-C9) CHECKED ‘YES’ AND SPECIFY THE LEVEL OF SUICIDE RISK AS INDICATED IN THE DIAGNOSTIC BOX: | NO | YES | |
SUICIDE RISK CURRENT | |||
1–8 points 9–16 points >17 points | Low Moderate High | ||
MAKE ANY ADDITIONAL COMMENTS ABOUT YOUR ASSESSMENT OF THIS PATIENT’S CURRENT AND NEAR FUTURE SUICIDE RISK IN THE SPACE BELOW: |