Preventing and Healing Stress Related Depression, Anxiety and Childhood Behavior
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Adult Trauma History Questionnaire

 

INSTRUCTIONS FOR MENTAL HEALTH WORKERS OR PHYSICIANS
Taking a Trauma History

As a part of your intake for a medical or psychological examination, consider the importance of asking about trauma. Increasing research indicates that traumatic experience may be at the root of a wide range of problems, from physical symptoms (such as headaches, allergies, pains) to emotional symptoms (depression, anxiety, panic attacks, etc.) to difficult behaviors (substance use, self-injury, acting out, verbal/emotional outbursts, suicidal thoughts or attempts, etc.). Many DSM diagnoses may eventually be determined to have their roots in trauma.

You may opt to use this as a checklist and simply ask about each point. A better way, if you have the time as part of your first few sessions, is to use these points as a guide for a conversation, listening for each type of issue as you ask general questions, and leading to more specific questions. There is a value in hearing what events or experiences arise for the patient/client before you ask about particulars.

Trauma is defined as the person's experience of a situation, not the situation itself. Not all traumatic events or experiences are recognized, especially if they are not the obvious, dramatic kind. Try to elicit information from throughout the entire lifespan. This is not an exhaustive list, but a guide for exploration.

 

INSTRUCTIONS FOR AN INDIVIDUAL
Your Personal Trauma History

Trauma is defined as a person's experience of a situation, not the situation itself. No two people will have the exact same reaction to a given situation, and no reaction is "wrong" or shameful. Not all traumatic events or experiences are easily recognized, especially if they are not the obvious, dramatic kind. This checklist will help you recall some situations you have experienced, or may help you realize that some events might have been traumatic, even though you did not think of them like that. You may also think of other things that are not on this list. You might want to discuss your list with a professional counselor or therapist to help you determine how much your personal history is interfering with your present life. A therapist can also help you get things back in balance, so that your past does not determine your future, or that of others in your life.

 

ADULT TRAUMA HISTORY

What are the three most traumatic things you have experienced?

1.

2.

3.

 

PRENATAL / PERINATAL HISTORY

__ Was your pregnancy planned? Were you a wanted child?
__ Were you premature? Were you in an incubator for more than two days?
__ Was your birth difficult?
__ Was your mother in poor physical or emotional health? Did she experience any losses or dramatic events during her pregnancy with you?
__ Did your parent(s) want a child of the opposite gender?
__ Were you adopted?
__ As an infant, were you separated from your mother at birth?
__ Did you have any medical problems or early hospitalization?
__ Were there other children in your family? Did you feel accepted by them?
__ Did your family have adequate food, shelter, and other basic needs met?
__ Did you feel loved?

 

PHYSICAL HISTORY

__ Have you had any hospitalizations, surgery, or serious illness?
__ Have you had any long-term or difficult medical treatments?
__ Have you had any life-threatening conditions?
__ Have you had any accidents (burns, falls, broken bones, auto, etc.)?
__ Have you had any difficult experiences with doctors, nurses, or hospitals? How did you respond?
__ Have you experienced chronic, unexplained physical ailments? What was going on in your life when symptoms were first apparent?
  __ headaches ______________________
  __ stomach aches ______________________
  __ colitis ______________________
  __ irritable bowel syndrome (IBS) ______________________
  __ autoimmune disorder ______________________
  __ joint pains ______________________
  __ skin conditions ______________________
  __ other ______________________

 

FAMILY RELATIONSHIPS

__ Were you separated from either parent or siblings for a lengthy period? Where/with whom did you live then?
__ Did any family members have alcohol or drug problems?
__ Did your parents fight -- verbally? physically? Did you hear / see these fights?
__ How were you punished or disciplined? Were you hit? How often? How severely?
__ Did you experience any incest, molestation, or inappropriate touch?
__ Did you have any serious fights with siblings? ongoing difficulties with siblings?
__ Were your parents married? Divorced? Remarried?
__ Were there any other relationships coming into the home?
__ How many caregivers did you have while growing up?
__ How many places did you live while growing up?

 

SCHOOL / WORK RELATED EXPERIENCES

__ Did you feel teased, tormented, bullied or threatened?
__ Did you feel excluded, outcast, or ostracized?
__ Did you experience prejudices?

 

FRIGHTENING EVENTS

__ Have you had any direct experience with human-caused assault (kidnapping, mugging, rape, arson, etc?)
__ Have you had any direct experience with nature-based fear (tornado, earthquake, flood, fire, etc?)
__ Have you witnessed any frightening events? What? At what age?
__ Do you have a close connection to someone who experienced a frightening event?
__ Have you had a frightening spiritual or religious experience?

 

LOSSES

__ Have you experienced any deaths of significant others? What circumstances?
__ Have you experienced the loss of a treasured pet?
__ Have you experienced the loss of a pregnancy? Through what means?
__ Have you experienced a serious break-up with good friends, boy/girlfriend, spouse or significant other?
__ Have you experienced a loss of job? What circumstances?
__ Have you experienced a loss of home? What circumstances?

 

OTHER UPSETTING LIFE EVENTS OR EXPERIENCES:

 

 

 

 

   
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