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TRAUMA IMPACT EVALUATION
TRAUMA IMPACT EVALUATION
By
juwonodutayo
July 6, 2024
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Name
*
Email
*
Phone
Gender
*
Female
Male
• Answer each statement honestly based on your feelings and experiences. • Use the scale provided to indicate how strongly you agree or disagree with each statement.
1 = Strongly Disagree
2 = Disagree
3 = Neutral
4 = Agree
5 = Strongly Agree
SECTION A
1. I have experienced physical abuse in my life.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
2. I have experienced emotional or psychological abuse in my life.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
3. I have experienced sexual abuse or assault.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
4. I have experienced neglect or abandonment.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
5. I have experienced a significant loss (e.g., death of a loved one).
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
6. I have experienced a traumatic accident or injury.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
7. I have witnessed violence or traumatic events.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
8. I have experienced a natural disaster (e.g., earthquake, flood).
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
9. I have experienced chronic illness or severe health issues.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
10. I have experienced other forms of trauma not listed above.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
SECTION B
11. I often feel anxious or fearful without a clear reason.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
12. I have frequent nightmares or flashbacks about past events.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
13. I find it difficult to trust others.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
14. I often feel emotionally numb or detached.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
15. I have difficulty managing my anger or emotions.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
16. I experience feelings of shame or guilt related to past events.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
17. I often feel overwhelmed or unable to cope with stress.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
18. I avoid people, places, or activities that remind me of past trauma.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
19. I have difficulty forming or maintaining relationships.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
20. I struggle with feelings of depression or hopelessness.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Next
SECTION C
21. I experience frequent headaches or migraines.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
22. I have chronic pain or physical discomfort.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
23. I have trouble sleeping or experience insomnia.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
24. I often feel fatigued or lacking in energy.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
25. I experience gastrointestinal issues (e.g., stomach aches, nausea).
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
26. I have difficulty breathing or experience shortness of breath.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
27. I have a weakened immune system or frequent illnesses
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
28. I engage in self-destructive behaviors (e.g., substance abuse, self-harm).
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
29. I have an eating disorder or disordered eating patterns.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
30. I experience other physical symptoms not listed above that may be related to stress or trauma.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
SECTION D
31. I have trouble concentrating or staying focused.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
32. I experience memory problems or difficulty recalling information.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
33. I often feel confused or disoriented.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
34. I have negative thoughts or beliefs about myself.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
35. I struggle with decision-making or problem-solving.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
36. I feel easily overwhelmed by everyday tasks.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
37. I have intrusive thoughts about past traumatic events.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
38. I have a negative outlook on the future.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
39. I often feel disconnected from reality.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
40. I experience other cognitive difficulties not listed above.
*
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Comment
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Assessment
Trauma
Trauma Impact Evaluation
Trauma Inventory
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