Trauma Symptom Survey

1. Feelings of helplessness and/or 0 1 2 3 4 5

powerlessness

2. Lack of focus or concentration 0 1 2 3 4 5

3. Gaps in memory — especially related 0 1 2 3 4 5

to traumatic events

4. Disorientation — confused about 0 1 2 3 4 5

time, space, direction

5. Prone to accidents 0 1 2 3 4 5

6. Feeling out of control 0 1 2 3 4 5

7. Feeling frozen, paralyzed, 0 1 2 3 4 5

immobile

8. Recurring dreams related to 0 1 2 3 4 5

traumatic event

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 9. Intrusive imagery related to traumatic 0 1 2 3 4 5
event (e.g. you can’t stop seeing the accident)

10. Flashbacks that make you feel 0 1 2 3 4 5

you are reliving the accident

11. Disrupted sleeping patterns: 0 1 2 3 4 5

insomnia or oversleeping (circle one)

12. Lethargy, exhaustion, 0 1 2 3 4 5

chronic fatigue

13. Night terrors or abrupt 0 1 2 3 4 5

awakening with intense fear

14. Extreme emotional shifts 0 1 2 3 4 5

15. Rage or anger outbursts 0 1 2 3 4 5

16. Overcautiousness 0 1 2 3 4 5

17. Fear of being watched or 0 1 2 3 4 5

followed

18. Startle easily or 0 1 2 3 4 5

“jumpy”

19. Feeling overwhelmed 0 1 2 3 4 5

20. Feeling defeated, inadequate, 0 1 2 3 4 5

can’t do anything

21. Feeling confused or fragmented 0 1 2 3 4 5

22. Too much energy 0 1 2 3 4 5

(hyperactivity)

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 23. Impulses to run away or escape 0 1 2 3 4 5
fantasies

24. Unable to feel weight of body, 0 1 2 3 4 5

feeling outside of yourself

25. Feeling physically heavy, like 0 1 2 3 4 5

dead weight

26. Losing personal items, such 0 1 2 3 4 5

as keys, glasses, etc.

27. Feeling disconnected, lost, 0 1 2 3 4 5

“not here”

28. Trouble keeping track of time, 0 1 2 3 4 5

late for appointments

29. Trouble orienting in space, i.e. 0 1 2 3 4 5

bumping into things

30. Avoidance of triggers or associations 0 1 2 3 4 5

with event (e.g. fear of driving on the highway)

31. Panic attacks 0 1 2 3 4 5

32. Feeling anxious 0 1 2 3 4 5

33. Nausea or vomiting 0 1 2 3 4 5

34. Shame 0 1 2 3 4 5

35. Self-judgment or self-blaming 0 1 2 3 4 5

36. Electric or overcharged feeling 0 1 2 3 4 5

in body

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 37. Obsessive review of incident, 0 1 2 3 4 5
constantly retelling the story

38. Disrupted eating patterns: 0 1 2 3 4 5

over-eating or under-eating (circle one)

39. Easily distracted 0 1 2 3 4 5

40. Chronic pain 0 1 2 3 4 5

41. Hypervigilance or feeling 0 1 2 3 4 5

“on guard”

42. Inability to cope with normal 0 1 2 3 4 5

stresses

43. Isolation from people 0 1 2 3 4 5

44. Constriction, suppression, 0 1 2 3 4 5

feeling shut down

45. Distrust 0 1 2 3 4 5

46. Little or no awareness 0 1 2 3 4 5

of choices

47. Disinterest in life 0 1 2 3 4 5

48. Generalized fear or anger 0 1 2 3 4 5

(e.g. believing all drivers are unsafe)

49. Excessive worrying 0 1 2 3 4 5

50. Disrupted relationships 0 1 2 3 4 5

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 51. Alienation, believing no one 0 1 2 3 4 5
can understand

52. Bonding with others through 0 1 2 3 4 5

trauma

53. Sudden fearfulness for no 0 1 2 3 4 5

apparent reason

54. Fearlessness of dangerous 0 1 2 3 4 5

situations

55. Uncontrolled temper 0 1 2 3 4 5

56. Desire to hurt self or others 0 1 2 3 4 5

57. Loss of sexual interest 0 1 2 3 4 5

58. Dizziness 0 1 2 3 4 5

59. Idea that someone can 0 1 2 3 4 5

control your thoughts

60. Fear of being alone 0 1 2 3 4 5

61. Fear of being with others 0 1 2 3 4 5

62. Crying easily 0 1 2 3 4 5

63. Inability to cry 0 1 2 3 4 5

64. Fear of leaving home or familiar 0 1 2 3 4 5

surroundings

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 65. “Everything’s fine”stance 0 1 2 3 4 5

66. No sense of future 0 1 2 3 4 5

67. Loss of creativity 0 1 2 3 4 5

68. Depression 0 1 2 3 4 5

69. Shakiness 0 1 2 3 4 5

70. Apathy, no energy for life 0 1 2 3 4 5

71. Feeling dead or in “no man’s 0 1 2 3 4 5

land”

72. Difficulty with starting projects 0 1 2 3 4 5

73. Starting many projects and not 0 1 2 3 4 5

completing them

74. Hypersensitivity to sound 0 1 2 3 4 5

or light

75. Get feelings hurt easily 0 1 2 3 4 5

76. Irritability, overreacting to 0 1 2 3 4 5

things

77. Compulsively rechecking 0 1 2 3 4 5

everything you do

78. Acting out, throwing objects, 0 1 2 3 4 5

screaming, hitting/kicking, shouting
(circle all that apply)

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 79. Everything seems burdensome or 0 1 2 3 4 5
daunting

80. Feeling weak in body, collapsed in 0 1 2 3 4 5

joints

81. Feeling doomed, as if something 0 1 2 3 4 5

bad is going to happen

82. Restlessness, can’t settle 0 1 2 3 4 5

83. Heart pounding, racing, 0 1 2 3 4 5

or irregular

84. Not remembering aspects 0 1 2 3 4 5

of traumatic event

85. Difficulty connecting or feeling 0 1 2 3 4 5

close to others

86. Difficulty making decisions 0 1 2 3 4 5

87. Guilt, regret, shame 0 1 2 3 4 5

88. Numbing, deadening of feeling 0 1 2 3 4 5

or sensation

89. Stomach problems, nausea, 0 1 2 3 4 5

upset, knots

90. Feelings of worthlessness, 0 1 2 3 4 5

inadequacy

91. Feeling your life is 0 1 2 3 4 5

still threatened

92. Increased urinary frequency 0 1 2 3 4 5

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 93. Temperature shifts — 0 1 2 3 4 5
chills or hot flashes

94. Futurized memory or the dread 0 1 2 3 4 5

trauma will occur

95. Feeling violated or unsafe 0 1 2 3 4 5

96. Emotional flooding (unable to 0 1 2 3 4 5

control emotions)

97. Feeling heightened sense of 0 1 2 3 4 5

urgency

98. Obsessive thinking about the 0 1 2 3 4 5

accident

99. Sense of horror as witness 0 1 2 3 4 5

to traumatic events

100. Feeling your life is in danger 0 1 2 3 4 5

since the traumatic event(s)

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