| RPT |
.| .| Status of Suicide Form| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
disliking yourself; having no self-esteem; having no self-respect): (1-Low self-hate, 5-High self-hate) <*Answer_6009*>| 5A) What I hate most about myself is:| <*Answer_6010*>|
5B) Rank of importance: <*Answer_6011*>| | 6) RATE OVERALL RISK OF SUICIDE: (1-Extremely low risk, 5-Extremely high risk) <*Answer_6012*>| | 7) How much is being suicidal related to
thoughts and feelings about yourself? (1-Not at all, 5-Completely) <*Answer_6013*>| | 8) How much is being suicidal related to thoughts and feelings about others? (1-Not at all, 5-Completely)
<*Answer_6014*>| | Copyright (c) David A. Jobes, Ph.D.| | 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 and procedures.| $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | Status of Suicide| | Pain (1-Low pain, 5-High pain): <-Pain->| Stress (1-Low stress, 5-High stress):
<-Stress->| Agitation (1-Low agitation, 5-High agitation): <-Agitation->| Hopelessness (1-Low hopelessness, 5-High hopelessness): <-Hopelessness->| Self-Hate (1-Low self-hate,
5-High self-hate): <-Self-Hate->| | Questions and Answers| | 1) RATE PSYCHOLOGICAL PAIN (hurt, anguish, or misery in your mind, not stress, not physical pain):(1-Low pain, 5-High pain)
<*Answer_5997*>| 1A) What I find most painful is:| <*Answer_5998*>| 1B) Rank of importance: <*Answer_5999*>| | 2) RATE STRESS (your general feeling of being pressured or
overwhelmed): (1-Low stress, 5-High stress) <*Answer_6000*>| 2A) What I find most stressful is:| <*Answer_6001*>| 2B) Rank of importance: <*Answer_6002*>| | 3) RATE
AGITATION (emotional urgency; feeling that you need to take action; not irritation; not annoyance): (1-Low agitation, 5-High agitation) <*Answer_6003*>| 3A) I most need to take action when:|
<*Answer_6004*>| 3B) Rank of importance: <*Answer_6005*>| | 4) RATE HOPELESSNESS (your expectation that things will not get better no matter what you do): (1-Low hopelessness,
5-High hopelessness) <*Answer_6006*>| 4A) I am most hopeless about:| <*Answer_6007*>| 4B) Rank of importance: <*Answer_6008*>| | 5) RATE SELF-HATE (your general feeling of
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