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Ask Suicide-Screening Questions (ASQ)

Ask Suicide-Screening Questions

Suicide Screening Questions

  1. In the past few weeks, have you wished you were dead?
    _____ Yes
    _____ No
     
  2. In the past few weeks, have you felt that you or your family would be better off if you were dead?
    _____ Yes
    _____ No
     
  3. In the past week, have you been having thoughts about killing yourself?
    _____ Yes
    _____ No
     
  4. Have you ever tried to kill yourself?
    _____ Yes
    _____ No

    If yes, how?

    __________________________________

    __________________________________

    __________________________________

    When?

    __________________________________

    __________________________________

    __________________________________

    If the patient answers yes to any of the above...
  5. Are you having thoughts of killing yourself right now?
    _____ Yes
    _____ No

Patient Name

__________________________________

Date

__________________________________

Medical Record # (or Patient Label)

__________________________________

National Institute of Mental Health