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Questionnaire template

Trauma Experiences and Stress Reactions

A non-diagnostic survey of adults' exposure to distressing events, stress reactions, life impact and support used.

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Healthcare · Mental health assessment. All Healthcare templates

Questions in this template

About You

  1. Thank you for taking part. Some questions touch on distressing experiences; you may skip any question you prefer not to answer, and your answers are kept confidential.

  2. This questionnaire is a screening aid, not a diagnosis. If you are in distress or feel unsafe, please contact a health professional or a local crisis service.

  3. What is your gender?

    Choose one:

    • Female
    • Male
    • Non-binary
    • Prefer not to say

  4. How old are you?

    A number from 16 to 100

  5. Has a health professional ever diagnosed you with post-traumatic stress disorder (PTSD)?

    Choose one:

    • Yes
    • No
    • Prefer not to say

  6. Has anyone close to you, such as a family member or partner, been diagnosed with PTSD?

    Choose one:

    • Yes
    • No
    • Prefer not to say

Distressing Events

  1. Have you ever gone through any of these kinds of events? Select all that apply.

    Choose any that apply:

    • Violence or abuse
    • A natural disaster
    • War or terrorism
    • A life-threatening illness or injury
    • Other
    • None of these

  2. What other kind of event did you go through?

    Condition: Only when Other was selected

    Open answer

  3. If you are comfortable doing so, briefly describe what happened and roughly when. (optional)

    Condition: Only for people who went through at least one event

    Open answer

Reactions and Their Impact

  1. Since the event or events, have you noticed any of the following?

    Condition: Only for people who went through at least one event

    • Unwanted, upsetting memories of what happened
    • Staying away from people, places or situations that remind you of it
    • Lasting changes for the worse in how you think or feel
    • Feeling constantly on guard, jumpy or easily irritated

    For each row: choose one:

    • Yes
    • Not sure
    • No

  2. How much have these experiences affected each part of your life?

    Condition: Only for people who went through at least one event

    • Physical health
    • Relationships with people close to you
    • Work or study
    • Social life
    • Emotional wellbeing

    For each row: choose one:

    • 1 - No impact
    • 2
    • 3
    • 4
    • 5 - Very high impact

Help and Support

  1. Have you ever gone to a professional for help with reactions like these?

    Choose one:

    • Yes
    • No
    • Prefer not to say

  2. What was that help like, and did it make a difference for you? (optional)

    Condition: Only for people who sought professional help

    Open answer

  3. Which kinds of support have you found helpful? Select all that apply.

    Choose any that apply:

    • Therapy or counselling
    • Medication
    • Self-care routines
    • Support groups
    • Mindfulness practice
    • None of these