C-SSRS Assessment

Patient Information: - Patient Name: John Doe - Date of Birth (DOB): 15 March 1985 Suicidal Ideation 1. Wish to be Dead - Have you thought about being dead or what it would be like to be dead? Yes (Patient expressed feeling overwhelmed and curious about what it would be like to not exist) - Have you wished you were dead or wished you could go to sleep and never wake up? Yes (Patient mentioned feeling this way during periods of intense stress) - Do you wish you weren’t alive anymore? No - Since last visit: Yes [X] No [ ] 2. Non-Specific Active Suicidal Thoughts - Have you thought about doing something to make yourself not alive anymore? No - Have you had any thoughts about killing yourself? Yes (Patient reported fleeting thoughts without specific plans) - Since last visit: Yes [X] No [ ] 3. Active Suicidal Ideation with Methods (Not Plan) Without Intent to Act - Have you thought about how you would do that or make yourself not alive anymore? No - Since last visit: Yes [ ] No [X] 4. Active Suicidal Ideation with Some Intent to Act Without Specific Plan - When you thought about making yourself not alive anymore, did you think this was something you might actually do? No - Since last visit: Yes [ ] No [X] 5. Active Suicidal Ideation with Specific Plan and Intent - Have you decided how or when you would make yourself not alive anymore? No - Have you planned out how you would do it? No - When making this plan, was any part of you thinking about actually doing it? No - Since last visit: Yes [ ] No [X] Intensity of Ideation - Most Severe Ideation: 2 - Non-Specific Active Suicidal Thoughts - Description: Patient reported fleeting thoughts of self-harm without specific plans or intent. - Frequency: 2 = A few times Suicidal Behavior Actual Attempt - Did you do anything to try to kill yourself or make yourself not alive anymore? No - Did you hurt yourself on purpose? No - Did you hurt yourself as a way to end your life? No - Did you want to die (even a little) when you hurt yourself on purpose? No - Were you trying to make yourself not alive anymore when you hurt yourself on purpose? No - Did you think it was possible you could have died from hurting yourself on purpose? No - Was this purely for reasons other than ending your life (e.g., to feel better or get a reaction)? No Self-Injurious Behavior (Non-Suicidal) - Has the patient engaged in non-suicidal self-injurious behavior? No - Since last visit: Yes [ ] No [X] Self-Injurious Behavior (Intent Unknown) - Has the patient engaged in self-injurious behavior where intent is unclear? No - Since last visit: Yes [ ] No [X] - Total Number of Suicide Attempts: 0 Interrupted Attempt - Has there been a time when you started to do something to end your life, but someone/something stopped you before acting? No - Since last visit: Yes [ ] No [X] - Total Number of Interrupted Attempts: 0 Aborted or Self-Interrupted Attempt - Has there been a time when you started to do something to end your life but stopped yourself before acting? No - Since last visit: Yes [ ] No [X] - Total Number of Aborted Attempts: 0 Preparatory Acts or Behavior - Have you done anything to prepare to end your life (e.g., giving away possessions, writing a goodbye note, acquiring means)? No - Since last visit: Yes [ ] No [X] - Total Number of Preparatory Acts: 0 Suicide Outcome and Lethality - Death by Suicide Since Last Visit: No - Most Lethal Attempt Date: N/A - Actual Lethality/Medical Damage: 0 - Potential Lethality (if no actual damage): 0