The Functional Assessment of Self-Mutilation (FASM)

A. In the past year, have you engaged in the following behaviors to deliberately harm yourself (check all that apply):
	Yes	No	How many times?	Have you gotten medical treatment?
Cut or carved on your skin
Hit yourself on purpose
Pulled your hair out
Gave yourself a tattoo
Picked at a wound
Burned your skin (ie, with a cigarette, match or other hot object)
Inserted objects under your nails or skin
Bit yourself (eg, your mouth or lip)
Picked areas of your body to the point of drawing blood
Scraped your skin
"Erased" your skin
Other: _______________
B. If not in the past year, have you EVER done any of the above acts?
_____ Yes
_____ No
If yes to any of the above behaviors in the past year, please complete the questions (C through H) below:
C. While doing any of the above acts, were you trying to kill yourself?
_____ Yes
_____ No
D. How long did you think about doing the above act(s) before actually doing it?
_____ None
_____ "A few minutes"
_____ <60 minutes
_____ >1 hour but <24 hours
_____ More than 1 day but less than a week
_____ Greater than a week
E. Did you perform any of the above behaviors while you were taking drugs or alcohol?
_____ Yes
_____ No
F. Did you experience pain during this self-harm?
_____ Severe pain
_____ Moderate pain
_____ Little pain
_____ No pain
G. How old were you when you first harmed yourself in this way? __________
H. Did you harm yourself for any of the reasons listed below? (check all reasons that apply): 0 = Never; 1 = Rarely; 2 = Some; 3 = Often
Reasons:				Rating
To avoid school, work, or other activities
To relieve feeling "numb" or empty
To get attention
To feel something, even if it was pain
To avoid having to do something unpleasant you don't want to do
To get control of a situation
To try to get a reaction from someone, even if it's a negative reaction
To receive more attention from your parents or friends
To avoid being with people
To punish yourself
To get other people to act differently or change
To be like someone you respect
To avoid punishment or paying the consequences
To stop bad feelings
To let others know how desperate you were
To feel more a part of a group
To get your parents to understand or notice you
To give yourself something to do when alone
To give yourself something to do when with others
To get help
To make others angry
To feel relaxed
Other: _______________
Thank you for your responses!

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The Functional Assessment of Self-Mutilation (FASM)