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Alexian Brothers Assessment of Self-Injury - Short Form

This 3 sentence summary provides the key details about the document: The document is a questionnaire that asks individuals to report on different self-injurious behaviors they have intentionally engaged in over the past year without suicidal intent, including cutting, burning, head banging, and not following medical advice, and to indicate how often each behavior occurred, when it began, and their motivations and feelings before and after self-injuring.

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1K views2 pages

Alexian Brothers Assessment of Self-Injury - Short Form

This 3 sentence summary provides the key details about the document: The document is a questionnaire that asks individuals to report on different self-injurious behaviors they have intentionally engaged in over the past year without suicidal intent, including cutting, burning, head banging, and not following medical advice, and to indicate how often each behavior occurred, when it began, and their motivations and feelings before and after self-injuring.

Uploaded by

salma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Alexian Brothers Assessment of Self-Injury – Short Form

Name: Date:

This questionnaire asks about a number of different things that people do to injure themselves.
Please read each question carefully and respond honestly.

For each of the behaviors listed below, tell us how often in the last year (12 months) you have
intentionally (on purpose) injure yourself without wanting to die. Please do not include
anything that was an accident or was done with the goal of killing yourself. If you didn’t do
the behavior in the last year, just leave it blank.

Number of:
In the last year, how often did you intentionally (on DAYS TIMES What age
purpose) do the following things to injure yourself did you
in the each Day start?
and/or cause pain: Past Year (on average)

1. Cut yourself enough to tear the skin and/or bleed

2. Scratched, rubbed, or pinched at your skin to the point of bruising


or bleeding

3. Burned or branded yourself

4. Tattooed or pierced yourself to injure yourself and/or cause pain

5. Choked yourself or constricted your own airway

6. Pulled out hair, eyelashes, or eyebrows to injure yourself and/or


cause pain

7. Drawn blood from yourself

8. Inserted or embedded objects into or under your skin

9. Hit yourself

10. Banged your head or any of your limbs against something

11. Prevented injuries or wounds from healing

12. Fallen down stairs to injure yourself and/or cause pain


Number of:
In the last year, how often did you intentionally (on DAYS TIMES What age
purpose) do the following things to injure yourself did you
in the each Day start?
and/or cause pain: Past Year (on average)
13. Carved into your skin (words, shapes, designs, etc…) to injure
yourself and/or cause pain

14. Broken your own limbs

15. Gouged at your eyes, ears or other bodily parts

16. Got into a fight to injure yourself or cause pain

17. Ingested/swallowed items to injure yourself or cause pain

18. Over-exercised to injure yourself or cause pain

19. Restricted your eating, purged (threw up), or used laxatives to


injure yourself or cause pain

20. Acted out sexually to injure yourself or cause pain

21. Not followed medical advice or made medical conditions worse to


injure yourself or cause pain

None of Some of Half of Most of All of


In the past year (12 months), how often did you: the Time the Time the Time the Time the Time
1. Have negative feelings or thoughts (distress, anger,
sadness, anxiety, tension, self-criticism, etc…)
immediately before self-injuring
2. Have difficulties or problems with other people
immediately before self-injuring
3. Experience a strong desire or urge to injure yourself
that was difficult to resist before self-injuring
4. Think often about injuring yourself
Strongly Strongly
When I self-injure, I expect that it will: Agree
Agree Unsure Disagree
Disagree
1. Provide relief from negative feelings or thoughts
2. Fix or resolve problems with other people
3. Create or increase positive feelings (happy, joyful,
excited, cheerful, etc…)

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