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Ask Suicide-Screening Questions (ASQ)

Ask Suicide-Screening Questions

Suicide-Screening Questions for the Emergency Department

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

How?

__________________________________

__________________________________

__________________________________

 

When?

__________________________________

__________________________________

__________________________________

 

Patient Name

__________________________________

Date

__________________________________

Medical Record # (or Patient Label)

__________________________________

National Institute of Mental Health