SBQ
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Birthday *
MM
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DD
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YYYY
Name *
Have you ever thought about or attempted to kill yourself in your lifetime? *
How often have you thought about killing yourself...
0- Not at all
1- Rarely
2- Sometimes
3- Often
4- Very often
In your lifetime
In the last year
Within 4 months
Within the last month
In the last several days including today
Clear selection
Have you ever told someone that you were going to commit suicide, or that you might do it... *
0- No
1- Yes, during one short period of time
2- Yes, more than one period of time
In your lifetime
In the last year
Within 4 months
Within the last month
In the last several days including today
What chance is there that you will consider the possibility, no matter how remote, of killing yourself... *
0- No chance at all
1
2- Some chance
3
4- Very likely
In your lifetime
Within the next year
Within the next 4 months
Within the next month
Today or in the next several days
How likely is it that you will attempt suicide... *
0- No chance at all
1
2- Some chance
3
4- Very likely
In your lifetime
Within the next year
Within the next 4 months
Within the next month
Today or in the next several days
If you did attempt suicide, for any reason, how likely is it that you would die as a result... *
0- No chance at all
1
2- Some chance
3
4- Very likely
In your lifetime
Within the next year
Within the next 4 months
Within the next month
Today or in the next several days
Do you currently have a plan for how you would go about killing yourself, if you decided to do it? *
Have you recently been planning for not being alive (for example, giving away your possessions or planning for someone to care for pets or manage your other responsibilities)? *
Sometimes people who decide to kill themselves want to do it but can not find a way to actually carry through with their plan because the means are not available to them. If you decided to kill yourself at this point in your life, would the means for carrying out such an action be available to you? *
If you decided to kill yourself at this point in your life, is there someone in your environment who would want to stop you? *
Some individuals say they cannot even imagine or conceive of the idea of attempting or committing suicide. For these people, suicidal behavior is as alien as the thought of becoming a tree or lifting the Empire State Building. Other people, even though they might never actually consider the idea, can at least imagine the idea of attempting or considering suicide. Which group of people do you belong to? *
Would any of your problems be solved if you committed suicide? *
Thinking about the way your life is today, that is, given the good things in your life now and any problems you might be having, IF you knew the QUALITY of your life would never change, that is, it would never get better or worse, do you feel that suicide would be a good way out? *
If the QUALITY of your life were to get worse (very bad), do you feel that attempting suicide would solve any of your problems? *
Have you ever written a suicide note, even if another person never read it? *
Have any of your family members or friends ever committed suicide? *
Have you ever deliberately hurt yourself physically (such as cut or burned yourself), but were not trying or expecting to die? *
The questions below apply to the last week. Select the most appropriate statements.
How often have you thought about injuring yourself or about how you want to injure yourself? *
At the most severe point, how strong was your urge to self-injure in the last week? *
How much time have you spent thinking about injuring yourself or about how you want to injure yourself? *
How difficult was it to resist injuring yourself in the last week? *
Keeping in mind your responses to the previous questions, please rate your overall average urge or desire to injure yourself in the last week. *
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