APPENDICES

S('H001, OF BEf1,kVlOURAL SCIENCES >1-1HATCIA (;:\ZDHI ITKIVERSITY

KCFTTAYARI

&sond-i)n:.; I 81 1 1 1

Ide~ltification No Ilate of lntewieii. Date oi' Adrnissiori

~ ~~

Dare of Ilischarge

I UEMOGRAI'i IIi i N I Z

1 Name of Patleilr > - Aye

> Sex .1 Keliyioii

:Marital Siatus 7 iype of i.imi;> S I'lace olreside:l:c

9 Occupational S I ~ I I I ,

10 Present arrangerncnr

1 1 i io. of Xlernbers (11 iairiiiy

12 Income per rnontli 1: Pa&.istory

Duration I4 Classification of5,\ic~6i.

hiale, Femoic

t4lndu. Chrlstihn. hluslim, Protestant. Others (specify) Cornmunitj FC, BC, SC, ST. X1FC. ,IfBC, 0 (specify) Illiterate, Prlni:iq. Secondary, HS, Graduaie. PGI Medicine, E n s . Lnu, Accourit\ b!B& BEd. Diploma, Others Single, Manled Seperateci. Divorced. Widov:. Remarriase, Others Sc~tnt, Nuclcir. ~ n d 1;n

'Town, Village, City (Slum, Flat). Sub-urban

Liiiskilled, Semi skilled, skilled Labor, Business Executive, Student, Police (o), Sales Rep, Er~sineer, doctor, L.iwyer, Teacher, Farmer, Defiance Servxe, Retired, Unempioyed, House uife. Clerical, SW, Others

With family, With dist relative, With friends, Alone, Lodge, .4panments .Adult hl F Children: M F M . .AdoIes, old .. , Divorced, Relatives <I500 1 = I 500 1 <SO00 ! :,=:5000

Previous arrernpr of suicide (lo. of time Onset W o Psychiatric Ilisorder Intolerable Pain. Ileliberating illness, Disability, .AIDS, STD, Cancer, Termrnkl illness, Alcoholism, Drugs, Self injury

i Kationai (I;, escape p.iin, etc), 2 Reaction (following loss), 3 Vengehl 1 (!o punish some one else), 4 hlanipulative (tolthwan) others plans, Psychotic (to 1 5 1 1 a de\ilsic~n), 6 Accidental (reconsidered tot! late). altn~istic, E~or idc , anomic

Fatalistic, Aggressive. ( l b . ; i \ ~ : i . . i : (~jbllgationl, 1.4~ (to ganies R Play), Solution. essay on of Consciousness, psychoIu~i~-~il i'aiii. Psycholoi.lciiI need, Hopeless comrnunlry. Comrnilnication of i n ~ e n t i o i ~ h b i v a l e n c e . i i : i~ r . i

1 Suicide Plan a lrnpulsivc ! J'lani!~.ri , 1 rl.lirle to decide h S.licidal tIiou~lil\ - 1 '1 : ,c.:lt ' t\hsezice / sir;:.^ iklontll.)

i I t l i d s - ( C C I : ~ I I I ! .'.i::jlability) li,~r??ing : i3uniiri: 1 Droiiniiig .' Oral ageiits / Slashins 1 (hhers

if oral aselit

d ) I'r~:par:i:,v~i I . ) V L . - ~ ! S u~ntempiatni anempt. 1 Procuring agent ~k~t is i i~rr is ,:-imiinc prescripiion. Ford piescription, Without prescriptioi5 O t h e r s ~ ~ ? Site at houhe. uiit.;~dc. !\li~rli. . I n presence (of others, Others present in adjoining room (Sleeping,

aw&e) 3 'Timing - [Specie exact time (if attempt] ... 4 Mode of poisoning Sinsic ilultiple agents Description (drug used, Quantity ) 2 Termination Behavior

- Intoxicated with alcohol, ('lew consc~ousriess, Diswcia:e& Others j Kature of Discover\

- Spontancaus c ~ ~ o i i ~ ~ u r i i ~ ~ . i ~ ~ i o n h i patient [ 5u:cide note! Confession 1 Other] - Patients Confes i~c atie; :i,:cmdental disaw.pr; Patient denied attempt ~ r \ i , 1 1 .ittcr discovery - Lmknouli to re!;irlie\ L ~ ~ I I ! admission

4 Lethality

Definitely Lethal. \ la\ rnai nut he 1,ethal. Yo: Lethal 5 Duration Retwecn

- Plan & ,\ttznipt

- Attempt k ili\cr,.,ur\ if ilrlayed Reasons - Discovery & 'ilz~r;-al ni;r~r~rion - Medical attcntii>rl ,! lii1c:\,ei\

Reponed Precipitnrils l'h\,!:lcal iilness rrlierpersonai, Interpersonal factors, I.!nemployment. I'O\.CW,., Farlure in I . \ ~ ~ I I ~ ~ I ~ : , I ~ I W

- According to Pat>cni - According to relalit c

7 Orher Data A Help sought before atteriipr Yes 1 Ko - Agency : GP. Specialist. Psych, Religior~s agency, and Social agency, Friends, Relatives, Other - Duration. - Cansulted for - Outcon~e b o change, Helpful, Recovered, Uncertain

B Previous Anenipt - Describe - h2etliod. Lcthali:? flospitalizatim~n

C Expecied Effects Outcorne Wish to die, l ) ~ d !lilt nund whsther alive or dead, Did not wan; to die, Uncertain

D hiorivi~tional Factors

To show love, To sccl~ he!;, I<: mahe things easlcr To escape from an imposs~ble situation, irricertain

E Legal Complicarion\

Before attempt ,iivarc. unaware After attempt a\iiire unaware

I)~stressing, not d~strrssins

~ , ~ p e c r s to be pun~siied. expects to be pardoned Others - Il;irac\~ii,~~!t. uncertain Diagnosis recorded b . tlrc in.;;ilriti,~ri

Nehra & Kulhar;~ PGIMER, Chandigrah.

Liniversit? of Calicut

(;url~eet Singh; Dalbir Kaur, Hasharan Kaur

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Coping Check List Ikpartment of CLinicaI Psychology, NIIMIIAVS

Kiran Rao, Su bha Krishna, Prabhu i:l:3agmsmu3

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