If you have Self Harmed and your injury needs hospital treatment you can print out this form, fill it in and take it with you.  If you have cut and your wound is spurting, please dial 999 (or the phone number for the emergency services in your country).

You can also download this form if you have Microsoft Word.

About Me:

My name is:

My address is:

My postcode is: 

My telephone number is:

 My date of birth is:

 I have bought a friend/advocate with me (please circle):  yes    no

My advocate's name is:
My advocate's address is:

My advocate's phone number is:
I would like my advocate to talk to you on my behalf (please circle):  yes    no

If possible I would like you to contact:

Person's name:
Person's phone number:

My next of kin is:

Next of kin's name:
Next of kin's phone number:

I have a crisis card (please circle):  yes    no
I have been to this hospital before (please circle):  yes    no

I have a GP/family doctor (please circle):  yes    no
My GP's name is:
My GP's address is:

The time I last ate was:         am/pm
I ate:
The time I last drank was:        am/pm
I drank:

I have health problems (please circle):  yes    no
The health problems I have are:

This injury is from (please circle):  Self Harm    Suicide attempt

About My Treatments:

My tetanus injections are up to date (please circle):  yes    no
My last tetanus injection was on:

I am allergic to:

I am take non-prescription drugs (please circle):  yes    no
The last non-prescription drug I took was:
I took the last non-prescription drug at:        am/pm

I am taking prescription drugs (please circle):  yes    no
The prescription drugs I am taking are:

I have bought my prescription drugs with me (please circle):  yes    no
The last prescription drug I took was:
I took this drug at:        am/pm

I am currently receiving other treatments (please circle):  yes    no
The other treatment I am currently receiving is:

I have had other treatments in the past (please circle):  yes    no
The treatments I had in the past were:

Any other information you need to know about me:

About My Injury:

I have opened up a previous wound (please circle):  yes    no
I have opened the wound by (please circle):    biting into the scab
                                                                   picking the scab off
                                                                   using a knife
                                                                   using a razor blade
                                                                   using glass
                                                                   using scissors
                                                                   using a craft knife
                                                                   using a pen knife

I have opened the wound by another method (please circle):  yes    no
The other method I have used is:

I have cut myself (please circle):  yes    no
I have cut myself with (please circle):  a razor blade
                                                         glass
                                                         scissors
                                                         a knife
                                                         a craft knife
                                                         a stanley knife

I have cut my myself with something else (please circle):  yes    no
The other thing I have used is:

I have marked on this drawing where I have cut myself:

Front:        Back:        

I have burnt myself (please circle):  yes    no
I have burnt myself with (please circle):  a flame
                                                             a cigarette
                                                             a heated object

I have burnt myself with something else (please circle):  yes    no
The other thing I have used is:

I have marked on this drawing where I have burnt myself:

Front:        Back:        

I have taken an overdose (please circle):  yes    no
The drug I have overdosed on is:
The strength of the drug is:
I have taken this quantity of the drug:
I have vomited since I took the overdose (please circle):  yes    no
There was blood in the vomit (please circle):  yes    no
The time I vomited was:        am/pm

I have had alcohol recently (please circle):  yes    no
The time I drank the alcohol was:        am/pm
The alcohol I had was:
The quantity of alcohol I drank was:

Any other information you need to know about my injury:

My Preferences:

Please examine my injury in a private room (please circle):  yes    no

I am upset/distressed (please circle):  yes    no

I need to be alone (please circle):  yes    no

I need someone to sit with me (please circle):  yes    no

I need my friend/advocate to sit with me (please circle):  yes    no

I am happy to sit in the main waiting room (please circle):  yes    no

I would like to wait somewhere quiet (please circle):  yes    no

I am happy for students to look at my wound (please circle):  yes    no

I am happy for students to treat my wound (please circle):  yes    no

I can talk about what happened (please circle):  yes    no

I can talk about why I did it (please circle):  yes    no

I would prefer to see a female doctor/nurse (please circle):  yes    no

I would prefer to see a male doctor/nurse (please circle):  yes    no

I would like to see a Social Worker (please circle):  yes    no

I would like to see a Psychiatrist (please circle):  yes    no

Please talk to my friend/advocate about my preferences (please circle):  yes    no

Any other information you need to know about my preferences:

Tell A Friend! Type In Your Name: Type In Your E-mail: Your Friend's E-mail: Your Comments: Receive copy:

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