Traumatic Life Events Checklist Form
Please indicate which traumatic life events you have experienced and provide brief details for each relevant event. This form is for informational purposes only and does not collect sensitive or regulated health information.
Full Name
First Name
Last Name
Age Range
Please Select
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Which of the following traumatic life events have you experienced? (Select all that apply)
*
Serious accident or injury
Natural disaster (e.g., earthquake, flood, fire)
Sudden loss of a loved one
Witnessing violence
Serious illness (self or close family)
Divorce or separation
Job loss or major financial hardship
Experience of crime (victim or witness)
Major life transition (e.g., migration, displacement)
Other
Briefly describe the serious accident or injury you experienced (if selected above)
Briefly describe the natural disaster you experienced (if selected above)
Briefly describe the sudden loss of a loved one you experienced (if selected above)
Briefly describe the violence you witnessed (if selected above)
Briefly describe the serious illness (self or close family) you experienced (if selected above)
Briefly describe any other traumatic life event you wish to share
Additional comments or notes
Submit Checklist
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