Q Never True Rarely True Sometimes True Often True Very Often True When I Was Growing Up

These questions ask about some of your experiences growing up as a child and a teenager.
For each
question, circle (or select in any other way if completing online) the number that best describes how you
feel. Although some of these questions are of a personal nature, please try to answer as honestly as you
can. Your answers will be kept confidential.
Q QUESTION NEVER RARELY SOMETIMES OFTEN VERY

TRUE TRUE TRUE TRUE OFTEN
TRUE
When I was growing up
1 I didn't have enough to eat. 1 2 3 4 5
2 I knew that there was someone to take 1 2 3 4 5
care of me and protect me.
3 People in my family called me things like 1 2 3 4 5
"stupid", "lazy", or "ugly".
4 My parents were too drunk or high to 1 2 3 4 5
take care of the family.
5 There was someone in my family who 1 2 3 4 5
helped me feel important or special
6 I had to wear dirty clothes 1 2 3 4 5
7 I felt loved. 1 2 3 4 5
8 I thought that my parents wished I had 1 2 3 4 5
never been born
9 I got hit so hard by someone in my 1 2 3 4 5
family that I had to see a doctor or go to
the hospital.
10 People in my family hit me so hard that it 1 2 3 4 5
left me with bruises or marks.
11 I was punished with a belt, a board, a 1 2 3 4 5
cord (or some other hard object).
12 People in my family looked out for each 1 2 3 4 5
other.
13 People in my family said hurtful or 1 2 3 4 5
insulting things to me.
14 I believe that I was physically abused. 1 2 3 4 5
15 I got hit or beaten so badly that it was 1 2 3 4 5
noticed by someone like a teacher,
neighbour, or doctor.
16 Someone in my family hated me. 1 2 3 4 5
17 People in my family felt close to each 1 2 3 4 5
other.
18 Someone tried to touch me in a sexual 1 2 3 4 5
way or tried to make me touch them.
19 Someone threatened to hurt me or tell 1 2 3 4 5
lies about me unless I did something
sexual with them.
20 Someone tried to make me do sexual 1 2 3 4 5
things or watch sexual things.
21 Someone molested me (took advantage 1 2 3 4 5
of me sexually).
22 I believe that I was emotionally abused. 1 2 3 4 5
23 There was someone to take me to the 1 2 3 4 5
doctor if I needed it
24 I believe that I was sexually abused. 1 2 3 4 5
25 My family was a source of strength and 1 2 3 4 5
support.
Please read each statement and circle a number 0, 1, 2, or 3 which indicates how much the
statement applied to you over the past week. There are no right or wrong answers.
Do not spend too much time on any statement. The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree or some of the time
2 Applied to me to a considerable degree or a good part of the time
3 Applied to me very much or most of the time.
1(s) I found it hard to wind down 0 1 2 3

2(a) I was aware of dryness of my mouth 0 1 2 3
3(d) I couldn’t seem to experience any positive feeling at all 0 1 2 3
4(a) I experienced breathing difficulty (e.g., excessively rapid breathing, 0 1 2 3
breathlessness in the absence of physical exertion)
5(d) I found it difficult to work up the initiative to do things 0 1 2 3
6(s) I tended to over-react to situations 0 1 2 3
7(a) I experienced trembling (e.g., in the hands) 0 1 2 3
8(s) I felt that I was using a lot of nervous energy 0 1 2 3
9(a) I was worried about situations in which I might panic and make a 0 1 2 3
fool of myself
10(d) I felt that I had nothing to look forward to 0 1 2 3
11(s) I found myself getting agitated 0 1 2 3
12(s) I found it difficult to relax 0 1 2 3
13(d) I felt down-hearted and blue 0 1 2 3
14(s) I was intolerant of anything that kept me from getting on with 0 1 2 3
what I was doing
15(a) I felt I was close to panic 0 1 2 3
16(d) I was unable to become enthusiastic about anything 0 1 2 3
17(d) I felt I wasn’t worth much as a person 0 1 2 3
18(s) I felt that I was rather touchy 0 1 2 3
19(a) I was aware of the action of my heart in the absence of physical 0 1 2 3
exertion (e.g., sense of heart rate increase, heart missing a beat)
20(a) I felt scared without any good reason 0 1 2 3
21(d) I felt that life was meaningless 0 1 2 3

Q Never True Rarely True Sometimes True Often True Very Often True When I Was Growing Up

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These questions ask about some of your experiences growing up as a child and a teenager.

Q QUESTION NEVER RARELY SOMETIMES OFTEN VERY

1(s) I found it hard to wind down 0 1 2 3

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