Trauma Exposure and Impact Survey
Please complete this confidential survey to help us understand your experiences and their impact. Your responses are anonymous and will be used for research or support purposes only.
Age
*
Gender
*
Female
Male
Non-binary
Prefer not to say
Other
Have you ever experienced or witnessed any of the following events? (Select all that apply)
*
Serious accident or injury
Natural disaster (e.g., earthquake, flood)
Physical assault
Emotional or psychological abuse
Loss of a loved one
Serious illness (self or close family)
Other (please specify)
How long ago did the most significant event occur?
*
Please Select
Within the past month
1-6 months ago
6-12 months ago
1-5 years ago
More than 5 years ago
How would you rate the impact of this event on your daily life?
*
No impact
1
2
3
4
5
6
7
8
9
Severe impact
10
1 is No impact, 10 is Severe impact
In the past month, how often have you experienced the following?
*
Rows
Never
Rarely
Sometimes
Often
Almost always
Unwanted memories or flashbacks
1
2
3
4
5
Difficulty sleeping
6
7
8
9
10
Feeling easily startled or on edge
11
12
13
14
15
Avoiding reminders of the event
16
17
18
19
20
Feeling emotionally numb
21
22
23
24
25
Have you ever sought professional help to cope with the impact of trauma?
*
Yes
No
Prefer not to say
If yes, what type of support did you receive? (Select all that apply)
Counseling or therapy
Medication
Support group
Family/friend support
Other (please specify)
How would you rate your current overall well-being?
*
1
2
3
4
5
Do you feel you currently need additional support or resources?
*
Yes
No
Not sure
Please share any additional comments or concerns (optional)
Submit Survey
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