1. Have you ever had a life-threatening illness?
No _____ Yes _____ If yes‚ at what age? __________
Duration of Illness _______________________
Describe specific illness ___________________________________________________
2. Were you ever in a life-threatening accident?
No _____ Yes _____ If yes‚ at what age? _________
Describe
accident____________________________________________________________
Did anyone die? ____ Who? (Relationship to you)__________________________
What physical injuries did you receive? _____________________________________
Were you hospitalized overnight? No_____ Yes _____
3. Was physical force or a weapon ever used against you in a robbery or mugging?
No _____ Yes _____ If yes‚ at what age? _________
How many perpetrators?___________
Describe physical force (e.g.‚ restrained‚ shoved) or weapon used against you.
Did anyone die? ______
Who?__________________________________________________
What injuries did you receive? _____________________________________________
Was your life in danger? __________________________
4. Has an immediate family member‚ romantic partner‚ or very close friend died because of accident‚ homicide‚ or suicide?
No _____ Yes _____ If yes‚ how old were you? ______
How did this person die? ____________________________________________________
Relationship to person lost __________________________________________________
In the year before this person died‚ how often did you see/have contact with him/her?
_____________________________
Have you had a miscarriage? No ______ Yes ______ If yes‚ at what age?___________
5. At any time‚ has anyone (parent‚ other family member‚ romantic partner‚ stranger or someone else) ever physically forced you to have intercourse‚ or to have oral or anal sex against your wishes‚ or when you were helpless‚ such as being asleep or intoxicated?
No _____ Yes _____ If yes‚ at what age? ________________
If yes‚ how many times? 1 _____‚ 2-4 _____‚ 5-10 _____‚ more than 10_____
If repeated‚ over what period? 6 mo. or less _____‚ 7 mos.-2 yrs. _____‚ more than 2 yrs. but less than 5 yrs. ______‚ 5 yrs. or more _________.
Who did this? (Specify stranger‚ parent‚ etc.) _____________________________
Has anyone else ever done this to you? No______ Yes______
6. Other than experiences mentioned in earlier questions‚ has anyone ever touched private parts of your body‚ made you touch their body‚ or tried to make you to have sex against your wishes?
No _____ Yes _____ If yes‚ at what age? ________________
If yes‚ how many times? 1 _____‚ 2-4 _____‚ 5-10 _____‚ more than 10_____
If repeated‚ over what period? 6 mo. or less _____‚ 7 mos.-2 yrs. _____‚ more
than 2 yrs. but less than 5 yrs. ______‚ 5 yrs. or more _________.
Who did this? (Specify sibling‚ date‚ etc.) _____________________________
What age was this person? ____________
Has anyone else ever done this to you? No______ Yes______
7. When you were a child‚ did a parent‚ caregiver or other person ever slap you repeatedly‚ beat you‚ or otherwise attack or harm you?
No _____ Yes_____ If yes‚ at what age _________________
If yes‚ how many times? 1 _____‚ 2-4 _____‚ 5-10 _____‚ more than 10 _______
If repeated‚ over what period? 6 mo. or less _____ ‚ 7 mos.- 2 yrs. _____‚ more than 2 yrs. but less than 5 yrs _____‚ 5 yrs. or more _______.
Describe force used against you (e.g.‚ fist‚ belt) _________________________
Were you ever injured? ______ If yes‚ describe ____________________________
Who did this? (Relationship to you) _______________________________________
Has anyone else ever done this to you? No ________ Yes ________
8. As an adult‚ have you ever been kicked‚ beaten‚ slapped around or otherwise physically harmed by a romantic partner‚ date‚ family member‚ stranger‚ or someone else?
No _____ Yes _____ If yes‚ at what age? _________________
If yes‚ how many times? 1 _____‚ 2-4 _____‚ 5-10 _____‚ more than 10______
If repeated‚ over what period? 6 mo. or less _____‚ 7 mos.- 2 yrs. _____‚ more than 2 yrs. but less than 5 yrs. ______ ‚ 5 yrs. or more _______.
Describe force used against you (e.g.‚ fist‚ belt) __________________________
Were you ever injured?_______ If yes‚ describe_______________________________
Who did this? (Relationship to you) ___________
If sibling‚ what age was he/she_____________________
Has anyone else ever done this to you? No_______ Yes ______
9. Has a parent‚ romantic partner‚ or family member repeatedly ridiculed you‚ put you down‚ ignored you‚ or told you were no good?
No _____ Yes _____ If yes‚ at what age? _________________
If yes‚ how many times? 1 _____‚ 2-4 _____‚ 5-10 _____‚ more than 10______
If repeated‚ over what period? 6 mo. or less _____‚ 7 mos.- 2 yrs. _____‚ more than 2 yrs. but less than 5 yrs. ______ ‚ 5 yrs. or more _______.
Who did this? (Relationship to you) ___________
If sibling‚ what age was he/she_____________________
Has anyone else ever done this to you? No_______ Yes ______
10. Other than the experiences already covered‚ has anyone ever threatened you with a weapon like a knife or gun?
No _______ Yes ______ If yes‚ at what age? _________________
If yes‚ how many times? 1 _____ ‚ 2-4 _____ ‚ 5-10 _____‚ more than 10______
If repeated‚ over what period? 6 mo. or less _____‚ 7 mos.- 2 yrs. _____‚ more than 2 yrs. but less than 5 yrs. ______‚ 5 yrs. or more _______.
Describe nature of threat
Who did this? (Relationship to you)
Has anyone else ever done this to you? No_____ Yes _____
11. Have you ever been present when another person was killed? Seriously injured? Sexually or physically assaulted?
No _____ Yes _____ If yes‚ at what age? _________________
Please describe what you witnessed
Was your own life in danger?
12. Have you ever been in any other situation where you were seriously injured or your life was in danger (e.g.‚ involved in military combat or living in a war zone)?
No________ Yes_______
If yes‚ at what age? __________ Please describe.
13. Have you ever been in any other situation that was extremely frightening or horrifying‚ or one in which you felt extremely helpless‚ that you haven’t reported?
No_____ Yes_____
If yes‚ at what age? _________ Please describe. ____________________________
This instrument can be found at: http://library.niwap.org/wp-content/uploads/2015/StressfulLifeEvents.pdf & http://faculty.uml.edu/darcus/47.375/aversive_exp/goodman_etal_slesq_98.pdf & https://georgetown.app.box.com/s/nzprmm2bn5pwzdw1l62w & https://libres.uncg.edu/ir/uncg/f/Graves_uncg_0154D_10859.pdf
Goodman‚ L. A.‚ Corcoran‚ C.‚ Turner‚ K.‚ Yuan‚ N.‚ & Green‚ B. L. (1998). Assessing traumatic event exposure: General issues and preliminary findings for the Stressful Life Events Screening Questionnaire. Journal of Traumatic Stress‚ 11: 521-542.
Corcoran‚ C. B.‚ Green‚ B. L.‚ Goodman‚ L. A.‚ & Krinsley‚ K. E. (2000). Conceptual and methodological issues in trauma history assessment. In A. Shalev‚ R. Yehuda‚ & A. McFarlane (Eds.)‚ Internationalhandbook of human response to trauma (pp. 223-232). New York: Plenum.
Green‚ B.L.‚ Chung‚ J.Y.‚ Daroowalla‚ A.‚ Kaltman‚ S.‚ & DeBenedictis‚ C. (2006). Evaluating the cultural validity of the Stressful Life Events Questionnaire. Violence against Women‚ 12‚ 1191-1213.