Concise Health Risk Tracking (CHRT) with Clinician Rated Behavioral Module Answer these questions based on how you are feeling today. Patient Name* First Last Today’s Date MM slash DD slash YYYY 1. I feel as if things are never going to get better. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 2. I have no future. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 3. It seems as if I can do nothing right. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 4. Everything I do turns out wrong. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 5. There is no one I can depend on. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 6. The people I care the most for are gone. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 7. I wish my suffering could just all be over. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 8. I feel that there is no reason to live. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 9. I wish I could just go to sleep and not wake up. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 10. I find myself saying or doing things without thinking. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 11. I often make decisions quickly or “on impulse.” Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 12. I often feel irritable or easily angered. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 13. I often overreact with anger or rage over minor things. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 14. I have been having thoughts of killing myself Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 15. I have thoughts about how I might kill myself. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree 16. I have a plan to kill myself. Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree Propensity ScoreImpulsivity ScoreRisk Score Δ
