childhood trauma

DOWNLOAD: Childhood Trauma Research Questionnaire 

Please email your completed questionnaire to Mandy: Mandyjkloppers@live.co.uk

Age: ___________________________
Gender Identity: _________________
Ethnicity: _______________________
Contact Details: (Optional) Name: _____________________________________
Email:__________________________________________
Mobile number:_________________________________

Part One  – Adverse Childhood Experiences (ACE)

While you were growing up, during your first 18 years of life:
  1. Did a parent or other adult in the household often

Swear at you, insult you, put you down, or humiliate you?

or

Act in a way that made you afraid that you might be physically hurt?

Yes                    No                                        If yes enter 1 ________

  1. Did a parent or other adult in the household often

Push, grab, slap, or throw something at you?

or

Ever hit you so hard that you had marks or were injured?

Yes                    No                                                If yes enter 1 ________

  1. Did an adult or person at least 5 years older than you ever…

Touch or fondle you or have you touched their body in a sexual way?

Or

Try to or actually have oral, anal, or vaginal sex with you?

Yes                    No                                                If yes enter 1 ________

  1. Did you often feel …

No one in your family loved you or thought you were important or special?

or

Your family didn’t look out for each other, feel close to each other, or support each other?

Yes                    No                                                If yes enter 1 ________

  1. Did you often feel …

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

Or

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

Yes                    No                                                If yes enter 1 ________

  1. Were your parents ever separated or divorced?

Yes                    No                                                If yes enter 1 ________

  1. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her?

Or

Sometimes or often kicked, bitten, hit with a fist,

Or

hit with something hard?

Or

Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

Yes                                      No                                                If yes enter 1 ________

  1. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?

Yes                                      No                                                If yes enter 1 ________

  1. Was a household member depressed or mentally ill or did a household member attempt suicide?

Yes                                      No                                                If yes enter 1 ________

  1. Did a household member go to prison?

Yes                                      No                                                If yes enter 1 ________

Now add up your “Yes” answers: _______________________ This is your ACE Score

Part Two – Resilience/ Positive Childhood Experiences (PCE)

  1. Are you always extra vigilant of the mood/emotions of those around you?                                   Yes (0)    No (1)
  2. Did you feel safe and protected at home?                                                                                           Yes (1)     No (0)
  3. Did you feel you could talk to your parents/family?                                                                            Yes (1)     No (0)
  4. If your parents weren’t loving or attentive, was there another significant adult who took their place and cared for you well? (eg. A grandparent or older sibling/Aunt/Uncle/school friend etc)

Yes (1)     No (0)

  1. Have your adult romantic relationships been fairly stable?                                                                Yes (1)     No (0)
  2. Do you suffer from low self-esteem or low confidence?                                                                     Yes (0)    No (1)
  3. Have you ever suffered from depression?                                                                                             Yes (0)    No (1)
  4. Have you ever suffered from panic attacks?                                                                                         Yes (0)    No (1)
  5. Have you ever suffered from anxiety?                                                                                                   Yes (0)    No (1)
  6. Do you suffer from angry outbursts, verbal and/or physical?                                                             Yes (0)    No (1)

Score for part 2:

Check your answers and add up the score next to it – one or zero. Total for Part Two: ­­­­______ PCE SCORE

The higher your score for part two, the more resilience you possess.

If you would be interested in sharing your childhood trauma story & possibly being included in my upcoming book on childhood trauma, please add your name and email address below: (you may remain anonymous in the book).

Sharing your story might help others to feel less alone in what they have been through.

Name: __________________________  Email address: ___________________________

Any questions/comments? Please email Mandy:  mandyjkloppers@live.co.uk

 

********  THANK YOU!   ********