Trauma Survey
Gender
Male
Female
Ethnicity
Black American
Caucasian
Asian
Hispanic
African
Other
Age
18-29
30-39
40-49
50-59
60-69
70+
Did you ever experience physical, sexual, or emotional abuse as a child?
Yes
No
Did you ever experience neglect (physical or emotional) as a child?
Yes
No
Did you ever witness violence or domestic abuse?
Yes
No
Did you ever experience a natural disaster or other traumatic event?
Yes
No
Did you ever experience the loss of a parent or other significant person?
Yes
No
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
Yes
No
Was a household member depressed or mentally ill, or did a household member attempt suicide?
Yes
No
Have you ever served in a war zone, or have you ever served in
a noncombat job that exposed you to war-related casualties (for
example, as a medic or on graves registration duty?)
Yes
No
Have you ever been in a serious car accident, or a serious
accident at work or somewhere else?
Yes
No
Have you ever been in a major natural or technological disaster,
such as a fire, tornado, hurricane, flood, earthquake, orchemical
spill?
Yes
No
Have you ever had a life-threatening illness such as cancer, a heart
attack, leukemia, AIDS, multiple sclerosis, etc.?
Yes
No
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?
Yes
No
Not including any punishments or beatings you already reported
in before question, have you ever been attacked, beaten, or mugged by
anyone, including friends, family members or strangers?
Yes
No
Has anyone ever made or pressured you into having some type of
unwanted sexual contact?
Yes
No
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?
Yes
No
Has a close family member or friend died violently, for example, in
a serious car crash, mugging, or attack?
Yes
No
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?
Yes
No
I did not have enough to eat.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I had someone to take care of me and protect me.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I’ve been called “stupid,” “lazy,” and/or “ugly.
Never True
Rarely True
Sometimes True
Often True
Very Often True
Someone helped me feel important.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I felt loved.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I felt/thought that my parents wished I had never
been born.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I got hit so hard that I had to see a doctor.
Never True
Rarely True
Sometimes True
Often True
Very Often True
There is nothing I want to change in my family.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I’ve been hit so hard that it left bruises and
marks.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I was punished with a belt, board, cord, or
another hard object.
Never True
Rarely True
Sometimes True
Often True
Very Often True
My family looked out for each other.
Never True
Rarely True
Sometimes True
Often True
Very Often True
My family said hurtful or insulting things to me.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I was physically abused.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I had a perfect childhood.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I got hit badly and it was noticed by a teacher,
neighbor, and/or doctor.
Never True
Rarely True
Sometimes True
Often True
Very Often True
Someone in my family hated me.
Never True
Rarely True
Sometimes True
Often True
Very Often True
My family felt close to each other.
Never True
Rarely True
Sometimes True
Often True
Very Often True
Someone tried to touch me in a sexual way or
tried to make me touch them.
Never True
Rarely True
Sometimes True
Often True
Very Often True
Someone threatened to hurt me unless I did
something sexual with them.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I have the best family in the world.
Never True
Rarely True
Sometimes True
Often True
Very Often True
Someone made me try to do sexual things/watch
sexual things.
Never True
Rarely True
Sometimes True
Often True
Very Often True
Someone molested me.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I was emotionally abused.
Never True
Rarely True
Sometimes True
Often True
Very Often True
Someone took me to see the doctor when I
needed to/if I needed to.
Never True
Rarely True
Sometimes True
Often True
Very Often True
I was sexually abused.
Never True
Rarely True
Sometimes True
Often True
Very Often True
My family gave me strength and support.
Never True
Rarely True
Sometimes True
Often True
Very Often True
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