Stolen : )
GENERAL INFORMATION
1. Age (in years): ..
2. Sex: Female
3. Country/State: Scotland
4. Occupation: Nothing
5. Sexual Orientation?
A. Heterosexual
B. Homosexual
C. Bi-sexual
D. Transgender Homosexual
E. Not Sure
6. What is your chosen religious affiliation?
A. Atheist or Agnostic
B. Buddhist
C. Catholic
D. Christian Protestant (Methodist, Baptist, Non-denominational, Presbyterian, etc.)
E. Church of Latter-day Saints
F. Hinduism
G. Islam
H. Judaism
I. Other eastern religions
J. Unitarian
K. Wicca
L. Other: I dont know.. i believe in something just not sure of what
M. None
BASICS OF SELF-INJURY
7. Which type(s) of self-injurious behaviors have you used? (list all that apply)
A. cutting
B. burning
C. stabbing
D. hitting
E. biting
F. banging
G. scratching
H. picking
I. scraping
J. bruising
K. wound interference
L. bone breaking
M. piercing or tattooing (for pain and/or SI only)
N. Other: _________
8. Location(s) of self-inflicted injuries? (list all that apply)
A. face
B. head
C. neck
D. shoulders
E. back
F. upper arms (below shoulder/ above elbow)
G. lower arms (below elbow/ above wrist)
H. wrists
I. hands
J. cuticles
K. chest
L. breasts
M. sides/hips
N. stomach
O. genitals
P. thighs
Q. lower legs (knees/calves/shins)
R. ankles
S. feet
T. other________
9. Do you typically try to hide the injuries?
A. Yes
B. No
C. Sometimes
10. How long have you been engaging in self-injurious behavior?
I dont know.
11. How consistent has the self-injury been?
A. Inconsistent since the start
B. Consistent since start
C. Gradual increase in severity
12. How often do you typically self-injure? (Time bound by duration of injury. i.e. cutting consistently for 10 minutes counts as one episode/ making a cut in the morning and another an hour later is 2 episodes)
A. Less than once a year
B. Once a year
C. 2-10x a year
D. Once a month
E. Every other week [depends on my mood]
F. Once a week
G. 2-6x a week
H. Once a day
I. 2 or more times a day
13. Which of these feelings, if any, trigger you to self-injure? (list all that apply)
A. anxiety
B. loss of control
C. depression
D. fear
E. anger
F. worthlessness
G. guilt
H.hopelessness
I. frustration
J. panic
K. numbness
L. disappointment
M. dissociation (feeling separated from reality)
N. loneliness
O. shame
P. other (please specify): self-hate
Q. no emotions trigger me
14. What emotion is most triggering to you?
I dont really know.. mostly hopelessness
15. What coping skills, if any, do you use to cope with the urge to SI?
If i hide everything that makes me think of cutting then it stops me from thinking bout it for a while
PAST
16. Have you ever been physically abused?
A. Yes
B. No
17. Have you ever been sexually abused?
A. Yes
B. No
18. Have you ever been emotionally abused?
A. Yes
B. No
19. If yes, in your opinion, is the abuse related to your SI?
A. Yes
B. No
C. Not sure
20. Have you experienced any other trauma?
A. Yes
B. No
21. If yes, is it related to your SI?
A. Yes
B. No
C. Not sure
22. Do you have an eating disorder?
A. Yes
B. No
C. sometimes
23. Have you ever had an eating disorder in the past?
A. Yes
B. No
24. Have you ever performed self-injury with the intention of suicide?
A. Yes
B. No
25. Have you ever attempted suicide?
A. Yes
B. No
FAMILY/FRIENDS
26. Have you told people about your self-injury?
A. I have not told anyone
B. I am generally comfortable talking to people about it.
C. I am out to a few people (specify the relationship [i.e. wife, friend, psychiatrist] and whether or not the disclosure was voluntary) Friends, Family, Some boyfriends, others
27. What, if anything, concerns you about coming out about your SI? (list all that apply)
A. rejection
B. feeling abnormal, bizarre or odd
C. being seen as abnormal, bizarre or odd
D. being forced into treatment or hospitalization
E. being treated differently in general
F. losing job or social status
G. being misunderstood
H. others being upset/hurt
I. being asked why
J. there is no fear about coming out
TREATMENT
28. Have you ever been to therapy for SI?
A. Yes
B. No
29. If yes, how helpful was the therapy:
A. very helpful
B. somewhat helpful
C. neutral
D. not helpful
E. harmful
F. can’t tell
30. Have you ever been hospitalized for SI?
A. Yes
B. No
31. If yes, was the hospitalization:
A. very helpful
B. somewhat helpful
C. neutral
D. not helpful
E. harmful
F. can’t tell
32. Have you been on medication for SI?
A. Yes
B. No
33. If yes, are/were they:
A. very helpful
B. somewhat helpful
C. neutral
D. not helpful
E. harmful
F. can’t tell