| Q15 | Do you drink alcohol? | -Yes -No | ||
| Q16 | If yes, how often? | -Occasionally -Once a week -Daily -Once a month | ||
| Q17 | Do you use tobacco or drugs? | -Yes -No | ||
|
| If yes, how often? | -Occasionally -Once a week -Daily -Once a month | ||
| Note: in the section below entitled “Suicide Risk Assessment Scale of Ducker”, please tick in the middle column in front of the items corresponding to your case | ||||
| E | Suicide Risk Assessment Scale of Ducker | |||
| Quote the highest level | ||||
| 0 | No death ideation |
| Don’t think about death more than usual | |
| 1 |
|
| Thinks about death more than usual | |
| 2 | Death ideation |
| Thinks often about death | |
| 3 |
|
| Has a few ideas concerning suicide | |
| 4 | Suicidal ideation |
| Often has ideas concerning suicide | |
| 5 |
|
| Very often has ideas concerning suicide and sometimes wishes to exist non more | |
| 6 | Passive desire to die |
| Wishes to die or to be dead | |
| 7 | a: strong link b: weak link |
| Very strong desire to die but is hold back by something | |
| 8 | Active will to die |
| Wants to end in his days | |
| 9 | a: long-term project b: short-term project |
| Knows how he wants to end in his days | |
| 10 | Start of acting out |
| Has already prepared his suicide or begun to act out | |
| F | The various remedies | |||
| Q18 | Have you ever talked about your thoughts of death or your desire to die? | Yes No | ||
| If so, to whom? | …………………. | |||
| What has been done? | …………………. | |||