CHILDHOOD TRAUMA QUESTIONNAIRE 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, check the box under the response that best describes how you feel. If you wish to change your response, put an “X” through the box and check your new choice.This field is hidden when viewing the formNameName* First Last Date MM slash DD slash YYYY 1. I didn’t have enough to eat. Never True Rarely True Sometimes True Often True Very Often True 2. I knew that there was someone to take care of me and protect me. Never True Rarely True Sometimes True Often True Very Often True 3. People in my family called me things like “stupid”, “lazy”, or “ugly”. Never True Rarely True Sometimes True Often True Very Often True 4. My parents were too drunk or high to take care of the family. Never True Rarely True Sometimes True Often True Very Often True 5. There was someone in my family who helped me feel that I was important or special. Never True Rarely True Sometimes True Often True Very Often True 6. I had to wear dirty clothes. Never True Rarely True Sometimes True Often True Very Often True 7. I felt loved. Never True Rarely True Sometimes True Often True Very Often True 8. I thought that my parents wished I had never been born. Never True Rarely True Sometimes True Often True Very Often True 9. I got hit so hard by someone in my family that I had to see a doctor or go to the hospital. Never True Rarely True Sometimes True Often True Very Often True 10. There was nothing I wanted to change about my family. Never True Rarely True Sometimes True Often True Very Often True 11. People in my family hit me so hard that it left me with bruises or marks. Never True Rarely True Sometimes True Often True Very Often True 12. I was punished with a belt, a board, a cord, or some other hard object. Never True Rarely True Sometimes True Often True Very Often True 13. People in my family looked out for each other. Never True Rarely True Sometimes True Often True Very Often True 14. People in my family said hurtful or insulting things to me. Never True Rarely True Sometimes True Often True Very Often True 15. I believed that I was physically abused. Never True Rarely True Sometimes True Often True Very Often True 16. I had the perfect childhood. Never True Rarely True Sometimes True Often True Very Often True 17. I got hit or beaten so badly that it was noticed by someone like a teacher, neighbor, or doctor. Never True Rarely True Sometimes True Often True Very Often True 18. I felt that someone in my family hated me. Never True Rarely True Sometimes True Often True Very Often True 19. People in my family felt close to each other. Never True Rarely True Sometimes True Often True Very Often True 20. Someone tried to touch me in a sexual way, or tried to make me watch sexual things. Never True Rarely True Sometimes True Often True Very Often True 21. Someone threatened to hurt me or tell lies about me unless I did something sexual with them. Never True Rarely True Sometimes True Often True Very Often True 22. I had the best family in the world. Never True Rarely True Sometimes True Often True Very Often True 23. Someone tried to make me do sexual things or make me watch sexual things. Never True Rarely True Sometimes True Often True Very Often True 24. Someone molested me. Never True Rarely True Sometimes True Often True Very Often True 25. I believe that I was emotionally abused. Never True Rarely True Sometimes True Often True Very Often True 26. There was someone to take me to the doctor if I needed it. Never True Rarely True Sometimes True Often True Very Often True 27. I believe that I was sexually abused. Never True Rarely True Sometimes True Often True Very Often True 28. My family was a source of strength and support. Never True Rarely True Sometimes True Often True Very Often True Δ
