Name *

First Name

Last Name

1. Serious natural disaster like a flood, tornado, hurricane, earthquake, or fire. *

Yes

No

2. Serious accident or injury like a car/bike crash, dog bite, or sports injury. *

Yes

No

3. Threatened, hit or hurt badly within the family. *

Yes

No

4. Threatened, hit or hurt badly in school or the community. *

Yes

No

5. Attacked, stabbed, shot at or robbed by threat. *

Yes

No

6. Seeing someone in the family threatened, hit or hurt badly. *

Yes

No

7. Seeing someone in school or the community threatened, hit or hurt badly. *

Yes

No

8. Someone doing sexual things to you or making you do sexual things to them when you couldn't say no. Or when you were forced or pressured. *

Yes

No

9. On line or in social media, someone asking or pressuring you to do something sexual. Like take or send pictures. *

Yes

No

10. Someone bullying you in person. Saying very mean things that scare you. *

Yes

No

11. Someone bullying you online. Saying very mean things that scare you. *

Yes

No

12. Someone close to you dying suddenly or violently. *

Yes

No

13. Stressful or scary medical procedure. *

Yes

No

14. Being around war. *

Yes

No

1. Upsetting thoughts or pictures about what happened that pop into your head. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

2. Bad dreams reminding you of what happened. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

3. Feeling as if what happened is happening all over again. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

4. Feeling very upset when you are reminded of what happened. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

5. Strong feelings in your body when you are reminded of what happened (sweating, heart beating fast, upset stomach). *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

6. Trying not to think about or talk about what happened. Or to not have feelings about it. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

7. Staying away from people, places, things, or situations that remind you of what happened. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

8. Not being able to remember part of what happened.

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

9. Negative thoughts about yourself or others. Thoughts like I won’t have a good life, no one can be trusted, the whole world is unsafe. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

10. Blaming yourself for what happened, or blaming someone else when it isn’t their fault. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

11. Bad feelings (afraid, angry, guilty, ashamed) a lot of the time. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

12. Not wanting to do things you used to do. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

13. Not feeling close to people. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

14. Not being able to have good or happy feelings. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

15. Feeling mad. Having fits of anger and taking it out on others. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

16. Doing unsafe things. *

0 = Never

1= Once in a while

2 = Half the time

3 = Almost always

17. Being overly careful or on guard (checking to see who is around you). *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

18. Being jumpy. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

19. Problems paying attention. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

20. Trouble falling or staying asleep. *

0 = Never

1 = Once in a while

2 = Half the time

3 = Almost always

1. Getting along with others *

Yes

No

2. Hobbies/Fun *

Yes

No

3. School or work *

Yes

No

5. General happiness *

Yes

No