Attachment 25 Trauumatic Life Events Questionnaire

Traumatic Life Events
The next few questions are about important life experiences that can affect a persons emotional
well-being or later quality of life.
The events listed below are far more common than people realize. Please read each question
carefully and mark the answers that best describe your experience.
Have you ever experienced a natural

disaster such as a flood, hurricane,
earthquake, etc.?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
1a
1b
1c
1d
(SKIP TO 2)
1e
Yes
No
Were you seriously injured?
Yes
No
Was someone you cared about

or close by seriously injured,
or killed?
Yes
No
Yes
No
How old were you when this

event first occurred or
happened to you?
AGE
Did you experience intense

fear, helplessness or horror
when it happened?
Did you think a loved one was

in danger of being killed by
the disaster?
Were you involved in a motor vehicle

accident for which you received
medical attention or that badly
injured or killed someone?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
2a
2b
2c
(SKIP TO 3)

when it happened?
Yes
No
Have you been in any other kind of

accident where you or someone else
was badly hurt? For example: a
plane crash, drowning or near
drowning, an electrical or machinery
accident, an explosion, home fire,
chemical leak, or overexposure to
radiation or toxic chemicals.
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
3a
Yes
No
3b

happened to you?
3c
AGE
(SKIP TO 4)

when it happened?
Yes
No
Yes
No

happened to you?
AGE
Have you lived, worked, or had

military service in a war zone?
Yes
No
4a
(SKIP TO 5)
Were you ever exposed to

warfare or combat? For
example, you were in the
vicinity of a rocket attack or
people being fired upon or
saw someone get wounded or
killed.
q
q
Have you experienced the sudden and

unexpected death of a close friend or
loved one?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
(SKIP TO 6)
Never
Once
Twice
3 times
Accident
4 times
Suicide
5 times
Murder
More than 5 times
77
Other
(SKIP TO 5)
5a
Was this due to an:
Specify:
4b

when it happened?
q
q
4c
4d
Yes
No
5b
Yes
No
5c

when it happened?
Yes
No

happened to you?
AGE

happened to you?
AGE
Has a loved one ever survived a life

threatening or permanently disabling
accident, assault or illness?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
(SKIP TO 7)
Have you ever had a life -threatening

illness?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
7a
6a

when it happened?
Yes
No
7b
6b

happened to you?
(SKIP TO 8)

when it happened?
Yes
No

happened to you?
AGE
AGE
Have you ever been robbed or been

present during a robbery where the
robber(s) used or displayed a
weapon?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
8a
8b
8c
(SKIP TO 9)
Yes
No
Yes
No
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
9b
9a

when it happened?
Have you ever been hit or beaten up

and badly hurt by a stranger or
someone you did not know well?
9c

happened to you?
(SKIP TO 10)

when it happened?
Yes
No
Yes
No

happened to you?
AGE
AGE
10
Have you seen a stranger or someone

you did not know very well attack or
beat up someone and seriously injure
or kill them?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
10a
10b
11
(SKIP TO 11)
Yes
No
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
11a

when it happened?
Has anyone ever threatened to kill

you or cause you serious physical
harm?

happened to you?
11b
AGE
11c
(SKIP TO 12)
Who did this to you?
Stranger
Friend/acquaintance
Relative
Intimate partner

when it happened?
Yes
No

happened to you?
AGE
12
While you were growing up, were you

physically punished in a way that
resulted in bruises, burns, cuts or
broken bones?
13
While you were growing up, did you

see or hear family violence such as
your father hitting your mother or
any family member beating up or
inflicting bruises, burns or cuts on
another family member?
Never
Once
Never
Twice
Once
3 times
Twice
4 times
3 times
5 times
4 times
More than 5 times
5 times
More than 5 times
12a
12b
(SKIP TO 13)

when it happened?
Yes
No
13a

happened to you?
13b
AGE
(SKIP TO 14)

when it happened?
Yes
No

happened to you?
AGE
14
Have you ever been slapped, punched,

kicked, beaten up, or otherwise
physically hurt by your spouse or
former spouse, boy/girlfriend, or
some other intimate partner?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
14a
14b
14c
14d
(SKIP TO 15)

when it happened?
Yes
No
Yes
No
Has more than one intimate

partner physically hurt you?
Yes
No

happened to you?
AGE
15
Before your 13 th birthday, did anyone

who was at least five years older than
you touch or fondle your body in a
sexual way or make you touch or
fondle their body in a sexual way?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
15a
15b
15c
15d
15e
(SKIP TO 16)
15f

when this event happened?
Yes
No

event firs t occurred or
happened to you?
AGE
Was the person a:
Stranger
Friend or acquaintance
Parent or caregiver
Other relative
Was threat or force used?
Yes
No
Yes
No
Was there oral, anal or

vaginal penetration?
Yes
No
16
Before your 13 th birthday, did anyone

close to your age touch sexual parts of
your body or make you touch sexual
parts of their body against your will
or without your consent?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
16a
16b
16c
16d
16e
(SKIP TO 17)
16f

fear, helplessness or
horror when this event
happened?
Yes
No

happened to you?
AGE
Was the person a:
Stranger
Relative
Yes
No
Yes
No

Yes
No
10
17
After your 13th birthday and before

your 18th birthday, did anyone touch
sexual parts of your body or make
you touch sexual parts of their body
against your will or without your
consent?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
17a
17b
17c
17d
17e
(SKIP TO 18)
17f

Yes
No

happened to you?
AGE
Was the person a:
Stranger
Relative
Intimate partner
Yes
No
Yes
No

Yes
No
11
18
After your 18 th birthday, did anyone

touch sexual parts of your body or
make you touch sexual parts of their
body against your will or without
your consent?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
18a
18b
18c
18d
18e
(SKIP TO C.19)
18f

Yes
No

happened to you?
AGE
Was the person a:
Stranger
Relative
Intimate partner
Yes
No
Yes
No

Yes
No
12
19
Has anyone ever stalked you? For

example, followed you or kept track
of your activities in a way that caused
you to feel intimidated or concerned
for your safety.
20
Have you or a romantic partner ever

had a miscarriage?
Never
Once
Twice
(SKIP TO C.21)
Never
Once
3 times
Twice
4 times
3 times
5 times
4 times
More than 5 times
5 times
More than 5 times
19a
19b
19c
(SKIP TO 20)
20a
Was the person a:
Stranger
Relative
Intimate partner
20b

Yes
No
20c

happened to you?

Yes
No
Did it ever happen after you

or your partner was
physically injured?
Yes
No

happened to you?
AGE
AGE
13
21
Have you or a romantic partner ever

had an abortion?
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
21a
21b
22
(SKIP TO 22)

Yes
No
Have you experienced or seen any

events that were life threatening,
caused serious injury, or were highly
disturbing or distressing? For
example, being lost in the wilderness,
a serious animal bite, violent death of
a pet, being kidnapped or held
hostage, or seeing a mutilated body or
body parts.
Never
Once
Twice
3 times
4 times
5 times
More than 5 times
22a
Please describe this experience

using the space below.
22b
Did you experience intens e


happened to you?
AGE
(SKIP TO 23)
22c
Yes
No

happened to you?
AGE
14
23 Of the events that you reported earlier in questions 1 through 22, please check the box
next to the ONE event that currently causes you the most distress.
None of these events happened to me
(SKIP TO NEXT SECTION)
Please only mark one item below.
Natural disaster
Motor vehicle accident
Other kind of accident
Combat or warfare
Sudden death of a friend or loved one
Life threatening illness of friend or loved one
Your own life threatening illness
Robbery where a weapon was used
10
An assault on you by an acquaintance or stranger
11
Witnessed severe assault to acquaintance or stranger
12
Threatened with death or serious harm
13
Were physically punished when you were growing up
14
Witnessed family violence when you were growing up
15
Physically hurt by an intimate partner
16
Sexual contact with someone at least 5 years older before you were age 13
17
Unwanted sexual contact with someone close to your age before you were age 13
18
Unwanted sexual contact as a teenager
19
Unwanted sexual contact as an adult
20
Being stalked
21
Miscarriage (yours or a partners)
22
Abortion (yours or a partners)
23
Some other traumatic event
15
24
Please think about the event you marked in the above question.
How old were you when this event first occurred or happened to you?
AGE
q
25
99
Less than one year old
When did this event last occurred or happened to you?

AGE
26
77
Event only happened once same age/time as noted above
99
Less than one year old
How much distress, anxiety, worry, sadness, frustration or grief does this event cause you?
No distress
Slight distress
Moderate distress
Considerable distress
Extreme distress
16

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Attachment 25 Trauumatic Life Events Questionnaire

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Traumatic Life Events

Have you ever experienced a natural

More than 5 times

Were you seriously injured?

Was someone you cared about

How old were you when this

Did you experience intense

Did you think a loved one was

Were you involved in a motor vehicle

More than 5 times

Did you experience intense

Have you been in any other kind of

More than 5 times

Were you seriously injured?

How old were you when this

Did you experience intense

Were you seriously injured?

How old were you when this

Have you lived, worked, or had

Were you ever exposed to

Have you experienced the sudden and

More than 5 times

More than 5 times

Was this due to an:

Did you experience intense

Were you seriously injured?

Did you experience intense

How old were you when this

How old were you when this

Has a loved one ever survived a life

More than 5 times

Have you ever had a life -threatening

More than 5 times

Did you experience intense

How old were you when this

Did you experience intense

How old were you when this

Have you ever been robbed or been

More than 5 times

More than 5 times

Were you seriously injured?

Did you experience intense

Have you ever been hit or beaten up

How old were you when this

Did you experience intense

Were you seriously injured?

How old were you when this

Have you seen a stranger or someone

More than 5 times

More than 5 times

Did you experience intense

Has anyone ever threatened to kill

How old were you when this

Who did this to you?

Did you experience intense

How old were you when this

While you were growing up, were you

While you were growing up, did you

More than 5 times

More than 5 times

Did you experience intense

How old were you when this

Did you experience intense

How old were you when this