| RPT |
|Columbia Suicide Severity Rating Scale (C-SSRS) - Version 2
| Gender: <.Patient_Gender.>
|
|<*Answer_7771*>
|
| Questions and Answers:
|
| 1. Over the past month, have you wished you were dead or wished you could
| go to sleep and not wake up?
| <*Answer_9589*>
| 2. Over the past month, have you had any actual thoughts of killing
|
| yourself?
| <*Answer_9590*>
| 3. Over the past month, have you been thinking about how you might do
| this?
| <*Answer_9591*>
| 4. Over the past month, have you had these thoughts and had some
| intention of acting on them?
| <*Answer_9592*>
| 5a. Over the past month, have you started to work out or worked out the
| details of how to kill yourself?
| Date Given: <.Date_Given.>
| <*Answer_9593*>
| 5b. If yes, at any time in the past month did you intend to carry out this
| plan?
| <*Answer_9594*>
| 6a. In your lifetime, have you ever done anything, started to do
| anything, or prepared to do anything to end your life (for example,
| collected pills, obtained a gun, gave away valuables, went to the
| roof but didn't jump)?
| <*Answer_9595*>
| 6b. If YES, was this within the past 3 months?
| Clinician: <.Staff_Ordered_By.>
| <*Answer_9596*>
|
|Columbia-Suicide Severity Rating Scale (C-SSRS) 2016 The Columbia
|Lighthouse Project. Scale may be reproduced without permission.
|
|Information contained in this note is based on a self-report assessment
|and is not sufficient to use alone for diagnostic purposes. Assessment
|results should be verified for accuracy and used in conjunction with
|other diagnostic activities.
| Location: <.Location.>
|
| Veteran: <.Patient_Name_Last_First.>
| SSN: <.Patient_SSN.>
| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
|
