PHYSICAL TRAUMA/ABUSE:

 

1. Are you currently in any physical pain?

2. Were you ever physically abused as a child or as an adult?

3. Are there times when you cannot be touched? (not hormonally related)

4. Were you ever slapped in the face? Did you ever slap someone you loved/cared about?

5. Do you have any intense physical sensations or pains that the doctors cannot explain?

6. Do you have headaches or migraines? Are they frequent? Did they begin after an accident?

7. Did family or friends “play jokes” on you that hurt you or caused you pain?

8. Were you ever in a serious accident? Any car accidents? Any serious head injuries?

9. Do you have a “temper”?

10. Have you ever become violent with your partner, spouse, children, or pets?

 

BODY SHAME:

 

11. Have you ever been shamed about your appearance?

12. Have people ever made fun of your body size or weight?

13. Does your perception of your body correspond to the perceptions of others?

14. Have you ever experienced an “eating disorder” such as compulsive overeating, bulimia, anorexia or a combination of these behaviors?

15. Is there anything about your body that you “hate”? Y N 

 

VERBAL/EMOTIONAL ABUSE:

 

16. Have you ever been verbally abused: teased, criticized, ridiculed, or humiliated by parents, teachers or others?

17. Were you ever told that you would never amount to anything or that you were “stupid”?

18. Were you ever told that you were an unwanted child or “an accident”?

19. Did you have a parent who was physically present but was emotionally absent?

 

SEXUAL ABUSE:

 

20. Were you provided the appropriate information about your sexual maturation to prevent traumatization? Was this information provided in a denigrating or demeaning way?

21. Are you consciously aware whether you ever sexually abused by another … used for the gratification of another person who was at least five years older or more mature?

22. Were you ever systematically or repeatedly abused sexually by someone?

23. Were you shamed about your sexual feelings or behaviors by parents, teachers, ministers, etc.?

 

INSOMNIA/SLEEP TRAUMA:

 

24. Did you have childhood or adulthood nightmares that still bother you?

25. Was your sleep ever disrupted by fighting, screaming, or domestic violence?

26. Do you have a “sleep disorder” or find yourself unable to get appropriate rest?

 

FAMILY/ABANDONMENT TRAUMA:

 

27. How large was your family? Were your needs for individual attention met?

28. Did you have a workaholic, alcoholic, or emotionally unavailable parent?

29. Did you have a parent/sibling with an addiction or compulsive behavior?

30. Was there any form of emotional or mental illness in the immediate family?

31. Was there a handicapped or disabled individual in the family while growing up?

32. Were you ever neglected or abandoned emotionally?

33. Were you ever a parent/spouse to one of your parents while growing up? (role reversal) Y N

 34. Did you have a healthy “same-sex” role model while growing up?

35. Did you “raise” your brother and sisters more than your parents did? (role reversal)

36. Did you have a healthy “opposite-sex” role model while growing up?

37. Did your parents ever divorce, leaving you with feelings of sadness, failure, or responsibility?

38. How well were your childhood needs met while growing up?

39. Were you taught/allowed to play as a child?

40. Have you ever been lost or accidentally left somewhere as a child (or adult)?

41. Did you “move” frequently as a child, preventing you from bonding with friends, schoolmates?

42. Were you taught to swim by being tossed into deep water?

43. Have you ever been discounted or ignored while reporting abuse that occurred to self or other?

 

FEAR/AXIETY/DEPRESSION:

 

44. Did you have a parent that was addicted, depressed, or mentally ill while you were growing up?

45. Do you have any overwhelming fears or phobias?

46. Do you ever experience panic attacks or sudden, unpredictable periods of shortness of breath?

47. Were you alone very much as a child?

48. Have you ever been prescribed an anti-depressant? What type and name? Current use?

 

GRIEF ISSUES:

 

49. Have you ever witnessed the death of another person?

50. Did you lose someone with whom you could not gain “closure” before s/he died?

51. Have you ever experienced the traumatic loss of or trauma from a pet/animal?

52. Have you ever felt spiritually abandoned … by God/Higher Power as a result of an experience?

53. Have you ever felt “heart-broken” by the demise of a close relationship?

 

SHAME ISSUES:

 

54. Were you ever shamed/humiliated for crying? (affect shame)

55. Were you ever shamed/humiliated for eating? (need shame) Y N

 56. Were you ever shamed/humiliated for being sexual or sexual exploration? (need shame)

57. Were you ever shamed/humiliated for being angry? (affect shame)

58. Have you ever given anyone the “silent treatment” or been treated in this way? For how long?

 

SOCIETAL, RELIGIOUS AND SPIRITUAL TRAUMA:

 

59. Have you ever witnessed violent abuse to another that you cared about?

60. Were you ever teased, tormented, or abused by your peers?

61. Have you ever been traumatized on the job?

62. Were you ever traumatized by a teacher, coach, or minister?

63. Have you ever been discriminated against due to race, gender, social status, sexual orientation, appearance, religion or beliefs?

64. Did you ever belong to or participate in a religion that repressed healthy emotional expression?

65. Have you ever had your intuitive or spiritual perceptions discounted by those close to you?

 

TRAUMA AND STRESS REACTIVITY:

 

66. Were you ever frightened by an experience to the extent that you “froze”?

67. Do you startle easily from touch or sounds?

68. Have you ever had a “flashback”?

69. In what types of situation do your “boundaries” simply disappear?

70. Have you ever been treated for a dissociative disorder or condition?

71. Do you have any significant “gaps” in your memory or recollection of your childhood?

72. Have you ever had an “out of body experience” (OBE) induced by an overwhelming event?

 

ENVIRONMENTAL TRAUMA AND TRIGGERS:

 

73. Have you ever been exposed to a “natural disaster”?

74. Were you ever exposed to a toxic or cancer-causing agent/chemical?

75. Were you or your loved ones ever in a “fire”?

76. Do you have any specific allergies or toxic reactions? Y N 

 

RELATIONSHIP DYSFUNCTION:

 

77. Have you been compulsive in your interpersonal relationships?

78. Are you “co-dependent” in relationships, evidencing feelings of dependency, excessive other-centeredness, inferiority and excessive receptivity to suggestions? Are you afraid of abandonment?

79. Are you “counter-dependent” in relationships, evidencing tendencies toward selfcenteredness, independence, and grandiosity? Are you afraid of being smothered?

80. Do you have any active addictions or compulsive behaviors? If you have an addiction, have you received inpatient or outpatient treatment or participated in a 12-Step group/process? Additional Notes: ___________________________________

Copyright ©2005 Brent M Baum.  All Rights Reserved Worldwide.  Revisions: June 2009, Feb. 2016, Sept. 2018

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