Have you been able to concentrate on what you are doing?
Yes
No
Have you lost much sleep recently?
Yes
No
Have you felt constantly under strain?
Yes
No
Do you consistently feel alone?
Yes
No
Do constantly recall bad memories?
Yes
No
How many times a week do you skip meals?
0
2
4
6
Have you ever thought about hurting yourself?
Yes
No
Have you ever hurt yourself?
Yes
No
Have you ever thought about killing yourself?
Yes
No
Have you ever attempted to kill yourself?
Yes
No
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