TRAUMA QUESTIONNAIRE
This is a brief questionnaire designed to assess trauma, and whether a person requires immediate (professional or non-professional), urgent or non-urgent intervention. It addresses primarily individual trauma, in no way to diminish the events, experiences or effects of both societal and communal trauma.

It is not administered by a registered health professional, and is merely a tool for assessment
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Please enter your name and surname: *
1. How would you rate your physical health? (1 – 10) (Eg. Sleeping, eating, rest, fitness, general wellness)
Poor
Excellent
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2. Are there any contributing factors (negative or positive) that are effecting your physical health? Please provide as much detail as possible.
3. How would you rate your emotional health? (1-10) (Eg you are in control of your emotions, they are balanced and diverse, you are confident and secure)
Poor
Excellent
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4. Are there any contributing factors (negative or positive) that are effecting your emotional health? Please provide as much detail as possible.
5. How would you rate your mental health? (1 – 10) (Eg concentration, ability to make decisions, constant negative thoughts)
Poor
Excellent
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6. Are there any contributing factors (negative or positive) that are effecting your mental health? Please provide as much detail as possible.
7. How would you rate your spiritual health? (1- 10) (Eg your relationship with Jesus, his word the bible and his people the church)
Poor
Excellent
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8. Are there any contributing factors (negative or positive) that are effecting your spiritual health? Please provide as much detail as possible.
9. EVENT: Answer the following questions, selecting a block if 'YES' and leaving blank if 'NO'
Has this ever happened to you?
If the event happened, did you think your life was in danger or you might be seriously injured?
If the event happened, were you seriously injured?
Have you ever had to treat someone with serious casualties or injury?
Have you ever been in a serious accident?
Have you ever been in a major natural or technological disaster, such as a fire, tornado, hurricane, flood, earthquake, or chemical spill?
Have you ever had a life-threatening illness?
Before age 18, were you ever physically punished or beaten by a parent, caretaker, or teacher so that: you were very frightened; or you thought you would be injured; or you received bruises, cuts, welts, lumps or other injuries?
Not including any punishments or beatings you already reported in Question 5, have you ever been attacked, beaten, or mugged by anyone, including friends, family members or strangers?
Has anyone ever made or pressured you into having some type of unwanted sexual contact? Note: By sexual contact we mean any contact between someone else and your private parts or between you and some else’s private parts
Have you ever been in any other situation in which you were seriously injured, or have you ever been in any other situation in which you feared you might be seriously injured or killed?
Has a close family member or friend died violently, for example, in a serious car crash, mugging, or attack?
Have you ever witnessed a situation in which someone was seriously injured or killed, or have you ever witnessed a situation in which you feared someone would be seriously injured or killed? Note: Do not answer “yes” for any event you already reported in Questions 1-9
10. Have you lost any significant relationships recently (within the last 10 – 15 years), either through death, loss, accident, or something else? If so, can you write their names down
11. Have you experienced any traumatic event not mentioned in question 9? Please describe your experience
12. Do you have recurring painful images, memories or thoughts of a specific event?
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13. Have there been any reminders that brought back feelings about it? If yes, please describe the reminder and the feelings that it brought up in you
14. If a miracle happened tonight, and everything was suddenly better, what would you notice tomorrow that would be different?
15. How often have you experienced each of the following in the last two months? 0= Never 3 = Often
0
1
2
3
Headaches
Insomnia
Weight loss (without dieting)
Stomach problems
Sexual problems
Feeling isolated from others
“Flashbacks” (sudden, vivid, distracting memories)
Restless sleep
Low sex drive
Anxiety attacks
Sexual overactivity
Loneliness
Nightmares
“Spacing out” (going away in your mind)
Sadness
Dizziness
Not feeling satisfied with your sex life
Trouble controlling your temper
Waking up early in the morning and can’t get back to sleep
Uncontrollable crying
Fear of men
Not feeling rested in the morning
Having sex that you didn’t enjoy
Trouble getting along with others
Memory problems
Desire to physically hurt yourself
Fear of women
Waking up in the middle of the night
Bad thoughts or feelings during sex
Passing out
Feeling that things are “unreal”
Unnecessary or over-frequent washing
Feelings of inferiority
Feeling tense all the time
Being confused about your sexual feelings
Desire to physically hurt others
Feelings of guilt
Feelings that you are not always in your body
Having trouble breathing
Sexual feelings when you shouldn’t have them
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16. In the past week, how much were you bothered by: 0= not at all 4= extremely
0
1
2
3
4
Repeated, disturbing, and unwanted memories of a stressful experience?
Repeated, disturbing dreams of the stressful experience?
Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?
Feeling very upset when something reminded you of the stressful experience?
Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?
Avoiding memories, thoughts, or feelings related to the stressful experience?
Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?
Trouble remembering important parts of the stressful experience?
Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?
Blaming yourself or someone else for the stressful experience or what happened after it?
Having strong negative feelings such as fear, horror, anger, guilt, or shame?
Loss of interest in activities that you used to enjoy?
Feeling distant or cut off from other people?
Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?
Irritable behavior, angry outbursts, or acting aggressively?
Taking too many risks or doing things that could cause you harm?
Being “superalert” or watchful or on guard?
Feeling jumpy or easily startled?
Having difficulty concentrating?
Trouble falling or staying asleep?
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