1. How distressed have you been with your life? Extremely distressed Very distressed Moderately distressed A little bit distressed Not at all distressed
2. How satisfied have you been with your life? Not satisfied at all Mildly satisfied Somewhat satisfied Satisfied Very Satisfied
3. How energetic and motivated have you been feeling? Not at all energetic and motivated A little bit energetic and motivated Somewhat energetic and motivated Energetic and motivated Very energetic and motivated
4. Feeling fearful, scared. Almost Always Often Sometimes A Little Bit Never
5. Alcohol/drug use interfering with your performance at school or work. Almost Always Often Sometimes A Little Bit Never
6. Wanting to harm someone. Almost Always Often Sometimes A Little Bit Never
7. Not liking yourself. Almost Always Often Sometimes A Little Bit Never
8. Difficulty concentrating. Almost Always Often Sometimes A Little Bit Never
9. Eating problem interfering with your relationships with your family or friends. Almost Always Often Sometimes A Little Bit Never
10. Thoughts of ending your life. Almost Always Often Sometimes A Little Bit Never
11. Feeling sad most of the time. Almost Always Often Sometimes A Little Bit Never
12. Feeling hopeless about the future. Almost Always Often Sometimes A Little Bit Never
13. Powerful, intense mood swings (highs and lows). Almost Always Often Sometimes A Little Bit Never
14. Alcohol/drug use interfering with your relationships with family and/or friends.(Select "Never" if you NEVER use alcohol or drugs) Almost Always Often Sometimes A Little Bit Never
15. Feeling nervous. Almost Always Often Sometimes A Little Bit Never
16. Heart pounding or racing. Almost Always Often Sometimes A Little Bit Never
17. Nonfamily Social Relationship/Friends (for example, communication, closeness, level of activity). Terrible Poorly Fair Well Very Well
18. Life Enjoyment (for example, recreation, life appreciation, leisure activities). Terrible Poorly Fair Well Very Well
19. Work/School (for example, performance, attendance). (Leave blank if this item does not apply) Terrible Poorly Fair Well Very Well
20. Intimate Relationships (for example, support, communication, closeness). (Leave blank if this item does not apply) Terrible Poorly Fair Well Very Well
Please indicate your overall risk of suicide. No risk Low risk Moderate risk High risk Extremely high risk
Your Initials:
The questions in this document are derived from the BHM-20® which is copyrighted work as listed below. No questions have been altered. The form was reformatted for ease of use. © By S. Mark Kopta and Jenny L. Lowry, 1997. All rights reserved.