Form Attachment D Attachment D Childhood Experiences Survey

Attachment D

Survey Instrument

OMB No. 0920-XXXX

Exp. Date:

Public Reporting burden of this collection of information is estimated at 27 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NW, MS D-24, Atlanta, GA 30333; Attn: PRA (0920-XXXX).

Childhood Experiences Survey

On this survey, we will ask you some questions about your health, relationships, and behaviors. We will ask about these during 3 different time periods: now (as an adult), and thinking back to when you were a teenager and when you were a child.

You will also be asked to compare some different health experiences and to choose which you would prefer. Finally, we will ask some questions about your childhood experiences.

Your responses are very important to public health. Your answers will help us to improve the health of others in the future.

There are no right or wrong answers. We are only interested in your experiences and opinions.

Your Health Status

Would you say that in general your health is…?

☐ Excellent

☐ Very good

☐ Good

☐ Fair

☐ Poor

Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

____

Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?

____

During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

____

In the past 30 days, how often did the following things happen? Please select one box per row.

	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight	☐	☐	☐	☐
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities	☐	☐	☐	☐
I felt depressed, afraid, or worthless	☐	☐	☐	☐
I felt like my emotions were out of control	☐	☐	☐	☐
I could not trust or maintain healthy relationships with other people	☐	☐	☐	☐
Illness, injuries, or accidents interfered with my daily activities	☐	☐	☐	☐
I felt limited by pain, discomfort, or my physical ability	☐	☐	☐	☐

Health as an Adult

Now please think about your health from age 18 to the present day.

From age 18 to the present day, on average, would you say that in general your health was…?

☐ Excellent

☐ Very good

☐ Good

☐ Fair

☐ Poor

From age 18 to the present day, on average, how often did the following things happen? Please select one box per row.

	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight	☐	☐	☐	☐
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities	☐	☐	☐	☐
I felt depressed, afraid, or worthless	☐	☐	☐	☐
I felt like my emotions were out of control	☐	☐	☐	☐
I could not trust or maintain healthy relationships with other people	☐	☐	☐	☐
Illness, injuries, or accidents interfered with my daily activities	☐	☐	☐	☐
I felt limited by pain, discomfort, or my physical ability	☐	☐	☐	☐

Health as a Teenager (Ages 12-17)

Now please think about your health as a teenager (ages 12-17).

As a teenager (ages 12-17), on average, would you say that in general your health was…?

☐ Excellent

☐ Very good

☐ Good

☐ Fair

☐ Poor

As a teenager (ages 12-17), on average, how often did the following things happen? Please select one box per row.

	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight	☐	☐	☐	☐
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities	☐	☐	☐	☐
I felt depressed, afraid, or worthless	☐	☐	☐	☐
I felt like my emotions were out of control	☐	☐	☐	☐
I could not trust or maintain healthy relationships with other people	☐	☐	☐	☐
Illness, injuries, or accidents interfered with my daily activities	☐	☐	☐	☐
I felt limited by pain, discomfort, or my physical ability	☐	☐	☐	☐

Health as a Child (Ages 5-11)

Now please think about your health as a child (ages 5-11).

As a child (ages 5-11), on average, would you say that in general your health was…?

☐ Excellent

☐ Very good

☐ Good

☐ Fair

☐ Poor

As a child (ages 5-11), on average, how often did the following things happen? Please select one box per row.

	Often	Sometimes	Rarely	Never
I was so angry that I felt like throwing things, screaming at someone, or picking a fight	☐	☐	☐	☐
I made risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfered with my daily activities	☐	☐	☐	☐
I felt depressed, afraid, or worthless	☐	☐	☐	☐
I felt like my emotions were out of control	☐	☐	☐	☐
I could not trust or maintain healthy relationships with other people	☐	☐	☐	☐
Illness, injuries, or accidents interfered with my daily activities	☐	☐	☐	☐
I felt limited by pain, discomfort, or my physical ability	☐	☐	☐	☐

Comparing Health

So far, we have asked you to describe your health in the past.

Now we are going to ask about what type of health you would like to have.

We will show you two different health profiles side-by-side.

We’ll then ask you to pick which you would prefer to have—if you had to pick between the two profiles.

Let’s begin with an example.

Comparing Health as an Adult

For each question, we will show you two profiles with the health aspects we just asked you about. For example:

As an adult with Profile A, you would often feel depressed, afraid or worthless, and never feel limited by pain, discomfort, or physical ability.

As an adult with Profile B, you would never feel depressed, afraid, or worthless, and often feel limited by pain, discomfort, or physical ability.

We will show this information side-by-side in a table like this.

Aspects		Profile A	Profile B
Feel depressed, afraid, or worthless		Often	Never
Feel limited by pain, discomfort, or physical ability		Never	Often

Then, we’ll ask you which profile you would prefer—if you had to choose between the two.

Which would you prefer?

☐

☐

Next, we’ll add one additional aspect. Suppose that your choice limited the number of years you live from today.

In the profile you chose, you would live 4 years from today, followed by death.

In the profile you did not choose, you would live 8 years from today, followed by death.

Thinking about this additional aspect, please choose which you would prefer.

		Profile A	Profile B
Years you would live from today followed by death		Live for 4 years	Live for 8 years
Which would you prefer?		☐	☐

The next questions will add the other aspects of health.

Adult Comparison #1

Compare the following two new health profiles for an adult. Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Never
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Often	Never
Feel like emotions are out of control		Sometimes	Rarely
Cannot trust or maintain healthy relationships with other people		Never	Never
Illness, injuries, or accidents interfere with daily activities		Rarely	Sometimes
Feel limited by pain, discomfort, or physical ability		Never	Often
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Never
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Often	Never
Feel like emotions are out of control		Sometimes	Rarely
Cannot trust or maintain healthy relationships with other people		Never	Never
Illness, injuries, or accidents interfere with daily activities		Rarely	Sometimes
Feel limited by pain, discomfort, or physical ability		Never	Often
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 4 years	Live for 8 years
Which would you prefer?		☐	☐

Adult Comparison #2

Compare the following two new health profiles for an adult. Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Rarely	Never
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Never	Never
Feel like emotions are out of control		Sometimes	Rarely
Cannot trust or maintain healthy relationships with other people		Never	Never
Illness, injuries, or accidents interfere with daily activities		Never	Rarely
Feel limited by pain, discomfort, or physical ability		Rarely	Sometimes
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Rarely	Never
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Never	Never
Feel like emotions are out of control		Sometimes	Rarely
Cannot trust or maintain healthy relationships with other people		Never	Never
Illness, injuries, or accidents interfere with daily activities		Never	Rarely
Feel limited by pain, discomfort, or physical ability		Rarely	Sometimes
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 8 years	Live for 10 years
Which would you prefer?		☐	☐

Adult Comparison #3

Compare the following two new health profiles for an adult. Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Rarely	Often
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Rarely	Rarely
Feel depressed, afraid, or worthless		Never	Never
Feel like emotions are out of control		Never	Sometimes
Cannot trust or maintain healthy relationships with other people		Sometimes	Sometimes
Illness, injuries, or accidents interfere with daily activities		Often	Rarely
Feel limited by pain, discomfort, or physical ability		Sometimes	Never
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Rarely	Often
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Rarely	Rarely
Feel depressed, afraid, or worthless		Never	Never
Feel like emotions are out of control		Never	Sometimes
Cannot trust or maintain healthy relationships with other people		Sometimes	Sometimes
Illness, injuries, or accidents interfere with daily activities		Often	Rarely
Feel limited by pain, discomfort, or physical ability		Sometimes	Never
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 6 years	Live for 7 years
Which would you prefer?		☐	☐

Comparing Health as a Teenager

Now we will ask about how you would compare health during ages 12-17. Again, we will show you two profiles. For example:

As a teenager with Profile A, you would often feel depressed, afraid or worthless, and never feel limited by pain, discomfort, or physical ability.

As a teenager with Profile B, you would never feel depressed, afraid, or worthless, and often feel limited by pain, discomfort, or physical ability

We will show this information side-by-side in a table like this.

Aspects		Profile A	Profile B
Feel depressed, afraid, or worthless		Often	Never
Feel limited by pain, discomfort, or physical ability		Never	Often

Then, we’ll ask you which profile you would prefer to have had as a teenager—if you had to choose between the two.

Which would you prefer?

☐

☐

Next, we’ll add one additional aspect. Suppose that your choice limited the number of years you live from today.

In the profile you chose, you would live 4 years from today, followed by death.

In the profile you did not choose, you would live 8 years from today, followed by death.

Thinking about this additional aspect, please choose which you would prefer.

		Profile A	Profile B
Years you would live from today followed by death		Live for 4 years	Live for 8 years
Which would you prefer?		☐	☐

Teenage Comparison #1

Compare the following two new health profiles that you could have had as a teenager (ages 12-17). Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Never
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Sometimes	Rarely
Feel depressed, afraid, or worthless		Sometimes	Often
Feel like emotions are out of control		Rarely	Sometimes
Cannot trust or maintain healthy relationships with other people		Often	Sometimes
Illness, injuries, or accidents interfere with daily activities		Never	Never
Feel limited by pain, discomfort, or physical ability		Never	Never
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Never
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Sometimes	Rarely
Feel depressed, afraid, or worthless		Sometimes	Often
Feel like emotions are out of control		Rarely	Sometimes
Cannot trust or maintain healthy relationships with other people		Often	Sometimes
Illness, injuries, or accidents interfere with daily activities		Never	Never
Feel limited by pain, discomfort, or physical ability		Never	Never
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 6 years	Live for 10 years
Which would you prefer?		☐	☐

Teenage Comparison #2

Compare the following two new health profiles that you could have had as a teenager (ages 12-17). Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Rarely	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Rarely	Often
Feel depressed, afraid, or worthless		Sometimes	Never
Feel like emotions are out of control		Often	Rarely
Cannot trust or maintain healthy relationships with other people		Never	Sometimes
Illness, injuries, or accidents interfere with daily activities		Sometimes	Sometimes
Feel limited by pain, discomfort, or physical ability		Rarely	Rarely
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Rarely	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Rarely	Often
Feel depressed, afraid, or worthless		Sometimes	Never
Feel like emotions are out of control		Often	Rarely
Cannot trust or maintain healthy relationships with other people		Never	Sometimes
Illness, injuries, or accidents interfere with daily activities		Sometimes	Sometimes
Feel limited by pain, discomfort, or physical ability		Rarely	Rarely
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 8 years	Live for 10 years
Which would you prefer?		☐	☐

Teenage Comparison #3

Compare the following two new health profiles that you could have had as a teenager (ages 12-17). Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Sometimes	Sometimes
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Sometimes	Rarely
Feel depressed, afraid, or worthless		Never	Sometimes
Feel like emotions are out of control		Rarely	Often
Cannot trust or maintain healthy relationships with other people		Often	Sometimes
Illness, injuries, or accidents interfere with daily activities		Rarely	Rarely
Feel limited by pain, discomfort, or physical ability		Rarely	Rarely
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Sometimes	Sometimes
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Sometimes	Rarely
Feel depressed, afraid, or worthless		Never	Sometimes
Feel like emotions are out of control		Rarely	Often
Cannot trust or maintain healthy relationships with other people		Often	Sometimes
Illness, injuries, or accidents interfere with daily activities		Rarely	Rarely
Feel limited by pain, discomfort, or physical ability		Rarely	Rarely
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 5 years	Live for 6 years
Which would you prefer?		☐	☐

Comparing Health as a Child

Finally, we will ask about how you would compare health during ages 5-11. Again, we will show you two profiles. For example:

As a child with Profile A, you would often feel depressed, afraid or worthless, and never feel limited by pain, discomfort, or physical ability.

As a child with Profile B, you would never feel depressed, afraid, or worthless, and often feel limited by pain, discomfort, or physical ability

We will show this information side-by-side in a table like this.

Aspects		Profile A	Profile B
Feel depressed, afraid, or worthless		Often	Never
Feel limited by pain, discomfort, or physical ability		Never	Often

Then, we’ll ask you which profile you would prefer to have had as a child—if you had to choose between the two.

Which would you prefer?

☐

☐

As before, we’ll add one additional aspect. Suppose that your choice limited the number of years you live from today.

In the profile you chose, you would live 4 years from today, followed by death.

In the profile you did not choose, you would live 8 years from today, followed by death.

Thinking about this additional aspect, please choose which you would prefer.

		Profile A	Profile B
Years you would live from today followed by death		Live for 4 years	Live for 8 years
Which would you prefer?		☐	☐

Childhood Comparison #1

Compare the following two new health profiles that you could have had as a child (ages 5-11). Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Often	Sometimes
Feel like emotions are out of control		Never	Never
Cannot trust or maintain healthy relationships with other people		Sometimes	Often
Illness, injuries, or accidents interfere with daily activities		Never	Never
Feel limited by pain, discomfort, or physical ability		Rarely	Never
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Often	Sometimes
Feel like emotions are out of control		Never	Never
Cannot trust or maintain healthy relationships with other people		Sometimes	Often
Illness, injuries, or accidents interfere with daily activities		Never	Never
Feel limited by pain, discomfort, or physical ability		Rarely	Never
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 4 years	Live for 7 years
Which would you prefer?		☐	☐

Childhood Comparison #2

Compare the following two new health profiles that you could have had as a child (ages 5-11). Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Often	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Rarely	Rarely
Feel depressed, afraid, or worthless		Never	Sometimes
Feel like emotions are out of control		Sometimes	Sometimes
Cannot trust or maintain healthy relationships with other people		Sometimes	Never
Illness, injuries, or accidents interfere with daily activities		Sometimes	Sometimes
Feel limited by pain, discomfort, or physical ability		Rarely	Often
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Often	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Rarely	Rarely
Feel depressed, afraid, or worthless		Never	Sometimes
Feel like emotions are out of control		Sometimes	Sometimes
Cannot trust or maintain healthy relationships with other people		Sometimes	Never
Illness, injuries, or accidents interfere with daily activities		Sometimes	Sometimes
Feel limited by pain, discomfort, or physical ability		Rarely	Often
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 6 years	Live for 8 years
Which would you prefer?		☐	☐

Childhood Comparison #3

Compare the following two new health profiles that you could have had as a child (ages 5-11). Please choose which you prefer.

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Often	Rarely
Feel like emotions are out of control		Rarely	Rarely
Cannot trust or maintain healthy relationships with other people		Rarely	Sometimes
Illness, injuries, or accidents interfere with daily activities		Rarely	Rarely
Feel limited by pain, discomfort, or physical ability		Sometimes	Never
Which would you prefer?		☐	☐

Aspects		Profile A	Profile B
Are so angry that you feel like throwing things, screaming at someone, or picking a fight		Never	Rarely
Make risky choices (such as unsafe sex, getting drunk, or taking drugs) that interfere with daily activities		Never	Never
Feel depressed, afraid, or worthless		Often	Rarely
Feel like emotions are out of control		Rarely	Rarely
Cannot trust or maintain healthy relationships with other people		Rarely	Sometimes
Illness, injuries, or accidents interfere with daily activities		Rarely	Rarely
Feel limited by pain, discomfort, or physical ability		Sometimes	Never
Which would you prefer?		☐	☐

Suppose that your choice limited the number of years you live from today.

Years you would live from today followed by death		Live for 4 years	Live for 8 years
Which would you prefer?		☐	☐

Childhood Experiences

For the last few sections of this survey, we would like to ask questions about your childhood experiences. Some of the questions may make you uncomfortable.

We recommend that you complete this section of the survey in a private place.

You may also take a break at any time. You may close your web browser and resume the survey later if you choose.

Remember that you can refuse to answer any question by leaving it blank.

These questions ask about some of your experiences growing up as a child and a teenager. Although these questions are of a personal nature, please try to answer as honestly as you can. For each question, place check the response that best describes how you feel.

When I was growing up …	Never True	Rarely True	Some-times True	Often True	Very Often True
I didn't have enough to eat.
I knew that there was someone to take care of me and protect me.
People in my family called me things like "stupid," "lazy," or "ugly."
My parents were too drunk or high to take care of the family.
There was someone in my family who helped me feel that I was important or special.
I had to wear dirty clothes.
I felt loved.
I thought that my parents wished I had never been born.
I got hit so hard by someone in my family that I had to see a doctor or go to the hospital.
There was nothing I wanted to change about my family.
People in my family hit me so hard that it left me with bruises or marks.
I was punished with a belt, a board, a cord, or some other hard object.
People in my family looked out for each other.
People in my family said hurtful or insulting things to me.
I believe that I was physically abused.
I had the perfect childhood.
I got hit or beaten so badly that it was noticed by someone like a teacher, neighbor, or doctor.
I felt that someone in my family hated me.
People in my family felt close to each other.
Someone tried to touch me in a sexual way, or tried to make me touch them.
Someone threatened to hurt me or tell lies about me unless I did something sexual with them.
I had the best family in the world.
Someone tried to make me do sexual things or watch sexual things.
Someone molested me.
I believe that I was emotionally abused.
There was someone to take me to the doctor if I needed it.
I believe that I was sexually abused.
My family was a source of strength and support.

For respondents with scores indicating emotional abuse, physical abuse, sexual abuse, or physical neglect the following question is shown:

You indicated the following about yourself:

• Bullet point 1

• Bullet point 2

• Bullet point 3

……

Thinking about these childhood events in particular, approximately when did any of these events first begin to occur?

1. Before age 5

2. Ages 5-11

3. Ages 12-17, and not earlier

4. Don’t know or not sure

For respondents with scores indicating emotional neglect the following question is shown:

You indicated the following about yourself:

• Bullet point 1

• Bullet point 2

• Bullet point 3

Approximately when did these events first stop occurring?

1. Before age 5

2. Ages 5-11

3. Ages 12-17, and not earlier

4. Don’t know or not sure

Other Experiences Before Age 18

You are now at the final section of the survey. To finish, we have a few other questions about your childhood before 18 years of age.

Were you ever put in foster care or put up for adoption?

• Yes

• No

When you were growing up, would you say your family was… ?

• Pretty well off

• About average financially

• Poor

For most of the time, did your family own their home?

• Yes

• No

• Not Sure

Did either of your parents or guardians ever receive public assistance, such as welfare, food stamps, or a food bank?

• Yes

• No

• Not Sure

What is the highest level of education that your mother (or main female caregiver) completed?

• Didn’t go to high school

• Some high school

• High school degree or GED

• Some college or technical school

• 4-year college degree or higher

• Not Sure

For most of the time, did your mother (or main female caregiver) work outside the home for pay?

• Yes

• No

• Not Sure

Was there a time of several months or more when your father (or main male caregiver) had no job?

• Yes

• No

• Not Sure

How old was your mother when you were born?

• 16 or younger

• 17-19

• 20-29

• 30-39

• 40 or older

As a child, did you ever see or hear one of your parents or guardians being hit, slapped, punched, shoved, kicked, or otherwise physically hurt by their spouse or partner?

• Yes

• No

• Not Sure

Which of the following best describes your parents’ marital status before you were 18?

• Always married or lived together

• Married until widowed or death

• Separated or divorced

• Never lived together

Were you an only child?

• Yes

• No

Did you live with anyone who suffered from mental illness or depression?

• Yes

• No

• Not Sure

Did you live with anyone who was a problem drinker or alcoholic?

• Yes

• No

• Not Sure

Did you live with anyone who used illegal drugs?

• Yes

• No

• Not Sure

Did you live with anyone who went to prison or committed a serious crime?

• Yes

• No

• Not Sure

About how many times did you move residences, even in the same town?

• 0 to 2

• 3 to 5

• 6 to 9

• 10 or more

• Not sure

Your own health state today

Finally, for the following questions, please indicate which statement in each group best describes your own health state today.

Mobility

• I have no problems in walking about

• I have some problems in walking about

• I am confined to bed

Self-Care

• I have no problems with self-care

• I have some problems washing and dressing myself

• I am unable to wash or dress myself

Usual Activities (e,g., work, study, housework, family or leisure activities)

• I have no problems with performing my usual activities

• I have some problems with performing my usual activities

• I am unable to perform my usual activities

Pain/Discomfort

• I have no pain or discomfort

• I have moderate pain or discomfort

• I have extreme pain or discomfort

Anxiety/Depression

• I am not anxious or depressed

• I am moderately anxious or depressed

• I am extremely anxious or depressed

About You

Finally, we have a few simple questions about you.

How many children, if any, have you had? Please include all for which you are the parent or legal guardian.

• None (0 children)

• 1 child

• 2 children

• 3 children

• 4 children

• 5 children

• 6 or more children

Which of the following describes your health insurance? Please check all that apply.

• Private health insurance, often provided by an employer

• Medicaid or other public insurance

• TRICARE (military health)

• No health insurance

• Not sure

Thank you for your help with this survey. We appreciate your responses.

Childhood Trauma Questionnaire™: A Retrospective Self-Report (CTQ™). Copyright © 1998 NCS Pearson, Inc. Computer adaption copyright © 2010 NCS Pearson, Inc. Adapted and reproduced with permission. All rights reserved. Childhood Trauma Questionnaire” and “CTQ” are trademarks in the US and/or other countries of Pearson Education, Inc. or its affiliates.

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