Adult Trauma History Questionnaire

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.

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.


What are the three most traumatic things you have experienced?





__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?


__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


__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?


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


__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?


__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?