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trauma history screen Child (THS)
Trauma History Screen – Child
20210610
Client Name
*
First
Last
Client Date of Birth
*
MM slash DD slash YYYY
Today's Date
*
MM slash DD slash YYYY
Directions: Ask how many times each event happened, and how much it affected the child when it happened and now.
How many times has this happened?
1. Have you ever been in or seen a very bad accident?
*
Never
Once
2-3 times
4-10 times
10 – times
2. Have you ever had someone you know been so badly injured or sick s/he almost died?
*
Never
Once
2-3 times
4-10 times
10 – times
3. Have you ever known somebody who died?
*
Never
Once
2-3 times
4-10 times
10 – times
4. Have you ever been so sick or hurt that you or the doctor thought you might die?
*
Never
Once
2-3 times
4-10 times
10 – times
5. Have you ever been unexpectedly separated from someone you depend on for love or security for more than a few days?
*
Never
Once
2-3 times
4-10 times
10 – times
6. Have you ever had somebody close to you tried to kill or hurt themself?
*
Never
Once
2-3 times
4-10 times
10 – times
7. Have you ever been physically hurt or threatened by someone?
*
Never
Once
2-3 times
4-10 times
10 – times
8. Have you ever been robbed or seen someone get robbed?
*
Never
Once
2-3 times
4-10 times
10 – times
9. Have you ever been kidnapped by somebody?
*
Never
Once
2-3 times
4-10 times
10 – times
10. Have you ever been in or seen a hurricane, earthquake, tornado, or bad fire?
*
Never
Once
2-3 times
4-10 times
10 – times
11. Have you ever been attacked by a dog or other animal?
*
Never
Once
2-3 times
4-10 times
10 – times
12. Have you ever seen or heard people physically fighting or threatening to hurt each other?
*
Never
Once
2-3 times
4-10 times
10 – times
13. Have you ever ever seen or heard somebody shooting a gun, using a knife, or using another weapon?
*
Never
Once
2-3 times
4-10 times
10 – times
14. Have you ever seen a family member arrested or in jail?
*
Never
Once
2-3 times
4-10 times
10 – times
15. Have you ever had a time in your life when you did not have the right care (e.g. food, clothing, a place to live)?
*
Never
Once
2-3 times
4-10 times
10 – times
16. Have you ever been forced to see or do something sexual?
*
Never
Once
2-3 times
4-10 times
10 – times
17. Have you ever seen or heard someone else being forced to do something sexual?
*
Never
Once
2-3 times
4-10 times
10 – times
18. Have you ever watched people using drugs (like smoking, sniffing, or using needles)?
*
Never
Once
2-3 times
4-10 times
10 – times
19. Have you ever seen something else that was very scary or where you thought somebody might get hurt or die?
*
Never
Once
2-3 times
4-10 times
10 – times
If yes to #19, explain
*
The worst time this happened, how much did it affect you?
1. Been in or seen a very bad accident?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
2. Had someone you know been badly injured or sick that s/he almost died?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
3. Known somebody who died?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
4. Been so sick or hurt that you or the doctor thought you might die?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
5. Been unexpectedly separated from someone who you depend on for love or security for more than a few days?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
6. Had somebody close to you tried to kill or hurt themself?
Not at all
A little bit
Moderately
Quite a bit
Extremely
7. Been physically hurt or threatened by someone?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
8. Been robbed or seen someone get robbed?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
9. Been kidnapped by somebody?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
10. Been in or seen a hurricane, earthquake, tornado, or bad fire?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
11. Been attacked by a dog or other animal?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
12. Seen or heard people physically fighting or threatening to hurt each other?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
13. Seen or heard somebody shooting a gun, using a knife, or using another weapon?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
14. Seen a family member arrested or in jail?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
15. Had a time in your life when you did not have the right care (e.g. food, clothing, a place to live)?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
16. Been forced to see or do something sexual?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
17. Seen or heard someone else being forced to do something sexual?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
18. Watched people using drugs (like smoking, sniffing, or using needles)?
Not at all
A little bit
Moderately
Quite a bit
EXtremely
19. Seen something else that was very scary or where you thought somebody might get hurt or die?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
If yes to #19, explain
*
How much does this STILL affect you?
1. Been in or seen a very bad accident?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
2. Had someone you know been so badly injured or sick that s/he almost died?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
3. Known somebody who died?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
4. Been so sick or hurt that you or the doctor thought you might die?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
5. Been unexpectedly separated from someone who you depend on for love or security for more than a few days?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
6. Had somebody close to you tried to kill or hurt themself?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
7. Been physically hurt or threatened by someone?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
8. Been robbed or seen someone get robbed?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
9. Been kidnapped by somebody?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
10. Been in or seen a hurricane, earthquake, tornado, or bad fire?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
11. Been attacked by a dog or other animal?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
12. Seen or heard people physically fighting or threatening to hurt each other?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
13. Seen or heard somebody shooting a gun, using a knife, or using another weapon?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
14. Seen a family member arrested or in jail?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
15. Had a time in your life when you did not have the right care (e.g. food, clothing, a place to live)?
*
Not at all
A little bit
Moderately
A quite bit
Extremely
16. Been forced to see or do something sexual?
*
Not at all
A little bit
Moderately
A quite bit
Extremely
17. Seen or heard someone else being forced to do something sexual?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
18. Watched people using drugs (like smoking, sniffing, or using needles)?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
19. Seen something that was very scary or where you thought somebody might get hurt or die?
*
Not at all
A little bit
Moderately
Quite a bit
Extremely
If yes to #19, explain
20. Which one of these bothers you the MOST right now, and how long ago did it happen?
*
Please click SUBMIT when complete
