Self-injury Treatment Checklist

These are questions you are likely to be asked when going to an emergency room/casualty ward for treatment of self-inflicted injuries. Fill out as much information as you can and click the submit button; a version of this page with your answers filled in will come up on your browser. You can print it out and take it with you when you go for treatment.
(adapted from NSHN; thanks to Ianna for originally making it into HTML)

About me

Name	My last tetanus injection was on
Complete address:	Medications I'm allergic to:
Telephone #	Current medications:
Date of birth:	Other current treatment:
I last ate hours ago and ate:	Previous treatment:
I last drank at and drank:	I HAVE been to this hospital before true false
I HAVE NOT used drugs or alcohol today true false	If possible, please contact name phone
I last used drugs/alcohol at . I used	My next of kin is name phone
I have medical insurance: true false	My insurance information will be attached to this form true false

About my injury

Choose true for the items that describe the injury you need treated. For example, if you burnt yourself with hot metal, check true for "I have burnt myself," fill in "hot metal" in the blank after "with," and check that item true. Choose false for the others.

I have cut myself
true
false

with

I have burnt myself
true
false

with

I have overdosed
true
false

I have hit myself
true
false

with

Quantity and strength of drugs I ODed on:

I have hit a solid object
true
false

it was:

I have vomited
true
false
at

I have

About my current state of mind

My injury was NOT a suicide attempt true false
I need you to examine my injury in a private room true false	I will be okay having students observe or treat me true false
I am distressed true false	I am able to discuss what happened true false
I am angry true false	I prefer to be treated by a female doctor true false
I need to sit alone true false	I prefer to be treated by a male doctor true false
I need someone to wait with me true false	I would like to see a social worker true false
I will be okay sitting in the main waiting area true false	I would like to see a psychiatric liaison nurse/mental health aide true false
I need to wait somewhere quiet true false	I would like to see a psychiatrist true false

Other information to help you help me

(what was happening before I did this, how I feel now,
what I am hoping will happen now, etc).