Form No number No number Traumatic Life Events Questionnaire

Traumatic Life Events
The next few questions are about important life experiences that can affect a person’s 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.

1

Have you ever experienced a natural
disaster such as a flood, hurricane,
earthquake, etc.?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

1a

1b

1c

1d

(SKIP TO 2)

1e

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

Was someone you cared about
or close by seriously injured,
or killed?

q

1

Yes

q

2

No

q

1

Yes

q

2

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?

q

Did you think a loved one was
in danger of being killed by
the disaster?

1

2

Were you involved in a motor vehicle
accident for which you received
medical attention or that badly
injured or killed someone?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

2a

2b

2c

3

(SKIP TO 3)

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

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.

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

3a

Were you seriously injured?

q

1

Yes

q

2

No

3b

How old were you when this
event first occurred or
happened to you?
3c

AGE

(SKIP TO 4)

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

2

4

Have you lived, worked, or had
military service in a war zone?

q

1

Yes

q

2

No

4a

5

(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?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

(SKIP TO 6)

2

Never
Once

q

3

Twice

q

4

3 times

q

1

Accident

q

5

4 times

q

2

Suicide

q

6

5 times

q

3

Murder

q

7

More than 5 times

q

77

Other

1

(SKIP TO 5)

5a

Was this due to an:

Specify:
4b

Did you experience intense
fear, helplessness or horror
when it happened?

q
q
4c

4d

1

Yes

2

No

5b

Were you seriously injured?

q

1

Yes

q

2

No

5c

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

How old were you when this
event first occurred or
happened to you?
AGE

3

6

Has a loved one ever survived a life
threatening or permanently disabling
accident, assault or illness?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

7

(SKIP TO 7)

Have you ever had a life -threatening
illness?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

7a
6a

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No
7b

6b

How old were you when this
event first occurred or
happened to you?

(SKIP TO 8)

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

AGE

4

8

Have you ever been robbed or been
present during a robbery where the
robber(s) used or displayed a
weapon?

q

1

Never

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

q

8a

8b

8c

9

(SKIP TO 9)

1

Yes

q

2

No

1

Yes

q

2

No

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

9b

Were you seriously injured?

q

q

9a

Did you experience intense
fear, helplessness or horror
when it happened?

q

Have you ever been hit or beaten up
and badly hurt by a stranger or
someone you did not know well?

9c

How old were you when this
event first occurred or
happened to you?

(SKIP TO 10)

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

AGE

5

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?

q

1

Never

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

q

10a

10b

11

(SKIP TO 11)

1

Yes

q

2

No

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

11a

Did you experience intense
fear, helplessness or horror
when it happened?

q

Has anyone ever threatened to kill
you or cause you serious physical
harm?

How old were you when this
event first occurred or
happened to you?

11b

AGE

11c

(SKIP TO 12)

Who did this to you?

q

1

Stranger

q

2

Friend/acquaintance

q

3

Relative

q

4

Intimate partner

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

6

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?

q

1

Never

q

2

Once

q

1

Never

q

3

Twice

q

2

Once

q

4

3 times

q

3

Twice

q

5

4 times

q

4

3 times

q

6

5 times

q

5

4 times

q

7

More than 5 times

q

6

5 times

q

7

More than 5 times

12a

12b

(SKIP TO 13)

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

13a

How old were you when this
event first occurred or
happened to you?

13b

AGE

(SKIP TO 14)

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

7

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?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

14a

14b

14c

14d

(SKIP TO 15)

Did you experience intense
fear, helplessness or horror
when it happened?

q

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

Has more than one intimate
partner physically hurt you?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

8

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?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

15a

15b

15c

15d

15e

(SKIP TO 16)
15f

Did you experience intense
fear, helplessness or horror
when this event happened?

q

1

Yes

q

2

No

How old were you when this
event firs t occurred or
happened to you?
AGE

Was the person a:

q

1

Stranger

q

2

Friend or acquaintance

q

3

Parent or caregiver

q

4

Other relative

Was threat or force used?

q

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

Was there oral, anal or
vaginal penetration?

q

1

Yes

q

2

No

9

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?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

16a

16b

16c

16d

16e

(SKIP TO 17)
16f

Did you experience intense
fear, helplessness or
horror when this event
happened?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

Was the person a:

q

1

Stranger

q

2

Friend or acquaintance

q

3

Relative

Was threat or force used?

q

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

Was there oral, anal or
vaginal penetration?

q

1

Yes

q

2

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?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

17a

17b

17c

17d

17e

(SKIP TO 18)

17f

Did you experience intense
fear, helplessness or horror
when this event happened?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

Was the person a:

q

1

Stranger

q

2

Friend or acquaintance

q

3

Relative

q

4

Intimate partner

Was threat or force used?

q

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

Was there oral, anal or
vaginal penetration?

q

1

Yes

q

2

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?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

18a

18b

18c

18d

18e

(SKIP TO C.19)
18f

Did you experience intense
fear, helplessness or horror
when this event happened?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

Was the person a:

q

1

Stranger

q

2

Friend or acquaintance

q

3

Relative

q

4

Intimate partner

Was threat or force used?

q

1

Yes

q

2

No

Were you seriously injured?

q

1

Yes

q

2

No

Was there oral, anal or
vaginal penetration?

q

1

Yes

q

2

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?

q

1

Never

q

2

Once

q

3

Twice

(SKIP TO C.21)

q

1

Never

q

2

Once

q

4

3 times

q

3

Twice

q

5

4 times

q

4

3 times

q

6

5 times

q

5

4 times

q

7

More than 5 times

q

6

5 times

q

7

More than 5 times

19a

19b

19c

(SKIP TO 20)

20a

Was the person a:

q

1

Stranger

q

2

Friend or acquaintance

q

3

Relative

q

4

Intimate partner

20b

Did you experience intense
fear, helplessness or horror
when this event happened?

q

1

Yes

q

2

No

20c

How old were you when this
event first occurred or
happened to you?

Did you experience intense
fear, helplessness or horror
when this event happened?

q

1

Yes

q

2

No

Did it ever happen after you
or your partner was
physically injured?

q

1

Yes

q

2

No

How old were you when this
event first occurred or
happened to you?
AGE

AGE

13

21

Have you or a romantic partner ever
had an abortion?

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

21a

21b

22

(SKIP TO 22)

Did you experience intense
fear, helplessness or horror
when this event happened?

q

1

Yes

q

2

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.

q

1

Never

q

2

Once

q

3

Twice

q

4

3 times

q

5

4 times

q

6

5 times

q

7

More than 5 times

22a

Please describe this experience
using the space below.

22b

Did you experience intens e
fear, helplessness or horror
when this event happened?

How old were you when this
event first occurred or
happened to you?
AGE

(SKIP TO 23)

22c

q

1

Yes

q

2

No

How old were you when this
event first occurred or
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.

q

1

None of these events happened to me

(SKIP TO NEXT SECTION)

Please only mark one item below.

q

2

Natural disaster

q

3

Motor vehicle accident

q

4

“Other” kind of accident

q

5

Combat or warfare

q

6

Sudden death of a friend or loved one

q

7

Life threatening illness of friend or loved one

q

8

Your own life threatening illness

q

9

Robbery where a weapon was used

q

10

An assault on you by an acquaintance or stranger

q

11

Witnessed severe assault to acquaintance or stranger

q

12

Threatened with death or serious harm

q

13

Were physically punished when you were growing up

q

14

Witnessed family violence when you were growing up

q

15

Physically hurt by an intimate partner

q

16

Sexual contact with someone at least 5 years older before you were age 13

q

17

Unwanted sexual contact with someone close to your age before you were age 13

q

18

Unwanted sexual contact as a teenager

q

19

Unwanted sexual contact as an adult

q

20

Being stalked

q

21

Miscarriage (yours or a partner’s)

q

22

Abortion (yours or a partner’s)

q

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

q

77

Event only happened once – same age/time as noted above

q

99

Less than one year old

How much distress, anxiety, worry, sadness, frustration or grief does this event cause you?

q

1

No distress

q

2

Slight distress

q

3

Moderate distress

q

4

Considerable distress

q

5

Extreme distress

16