Traumatic Antecedents Questionnaire
This questionnaire asks you to describe experiences you may have had as a young child (ages 0 to 6), as a school age child (ages 7-12), as an adolescent (ages 13-18) and as an Adult.  For each item, indicate the degree to which the statement describes your experience at each different age period.  The scale has both frequency and intensity words; please choose the highest applicable number.  If there are any age periods for an item that you are unable to answer, please indicate this by choosing DK ("don't know").
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Email *
For Each Question and Age Group Use the Highest Applicable Number:
0=never or not at all     1=rarely or a little bit     2=occasionally or moderately     3=often or very much     DK= don't know
Name, first and last
1 point
Date
1 point
MM
/
DD
/
YYYY
Age
1 point
Gender
1 point
Clear selection
1.  I generally feel safe and cared for. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
2.  Someone made sure I got up in the morning and went to school. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
3.  I was really good at something  (like sports, a hobby, school, work, or some creative activity). *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
4.  I had good friends. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
4.  I had good friends. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
5.  I felt close to at least one of my brothers or sisters. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
6.  Somebody in my family had so many problems that there was little left for me. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
7.  I felt that nobody cared whether I lived or died. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
8.  I had someone to talk with outside my family when something was bugging me at home. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
9.  My parents confided things in me that made me feel uncomfortable. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
10.  My parents were divorced or separated. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
11. I lived with different people at different times (like different relatives or foster families. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
12.  Somebody close to me died. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
13.  I had a serious illness and/or had to be hospitalized for a medical problem. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
14.  Someone I was close to was very sick, or in an accident for which they needed to be hospitalized. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
15.  I received news that someone close to me had been seriously injured or violently killed during an accident, fight, or a crime. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
16.  In my parents' eyes, nothing I did was ever good enough. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
17.  People in my family called me insulting names. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
18.  The rules in my family were unclear and inconsistent. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
19.  The punishments I received were unfair. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
20.  My parents hurt each other physically when they argued and fought. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
21.  I spent time out of the house and no one knew where I was. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
22.  People in my family were out of control. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
23.  I witnessed physical violence in my family. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
24.  Someone in my family got medical attention because of violence. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
25.  Someone in my family had a problem with alcohol and/or drugs. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
26.  I abused alcohol and/or drugs. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
27.  My caregivers were so into alcohol or drugs that they couldn't take care of me. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
28.  I was beaten, kicked or punched by someone close to me. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
29.  I was in a situation in which I was convinced I would be physically injured or lose my life. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
30.  Someone outside my family attacked me. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
31.  I saw dead bodies. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
32.  I was involved in a serious accident. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
33.  I was in a natural disaster. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
34.  I saw sexual things that scared me. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
35.  Someone (older) touched me sexually against my wishes or tried to make me touch them. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
36.  Someone forced me to have sex against my will. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
37.  Someone threatened me with physical harm unless I did something sexual. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
38.  I believed that one of my brothers or sisters was sexually molested. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
39.  I have had another very frightening or traumatic experience where I felt intense fear, helpless, or horrified.   *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
40.  Something terrible happened to me that still remains a mystery to me. *
4 points
0=never or not at all
1=rarely or a little bit
2=occasionally or moderately
3=often or very much
DK=don't know
0-6 years old
7-12 years old
13-18 years old
Adult
How upsetting was it to answer these questions? *
2 points
©Bessel A. van der Kolk, M.D.
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