• Questionnaire Instructions

    Estimated time to complete: 20–30 minutes; Please take your time and provide as much detail as possible when answering the following questions. Your responses will be reviewed by the Principal Investigator and used to help determine your eligibility for this trial. You will be asked about events that may have occurred at any point in your life, including childhood and adulthood. For each event, please select all options that apply. If an event applies to you in any way, do not select “Does not apply.” If you indicate that an event applies to you, you will be asked to provide additional details about the most impactful or worst instance of that event.

  • Please provide responses to the following questions about your childhood and upbringing:

  • PART 2 INSTRUCTIONS:

    Listed below are a number of difficult or stressful things that sometimes happen to people. Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events. There are 17 in total. For each event, check one or more of the boxes to indicate whether:(a) it happened to you personally;(b) you witnessed it happen to someone else;(c) you learned about it happening to a close family member or close friend;(d) you were exposed to it as part of your job (for example, paramedic, police, military, or other first responder);(e) you’re not sure if it fits; or(f) it doesn’t apply to you. If you have experienced these events please provide a brief summary of the worst event in that category below.
  • 1. Please indicate all that apply for the following event: Natural disaster (for example, flood, hurricane, tornado, earthquake)*
  • 2. Please indicate all that apply for the following event: Fire or explosion*
  • 3. Please indicate all that apply for the following event: Transportation accident (for example, car accident, boat accident, train wreck, plane crash)*
  • 4. Please indicate all that apply for the following event: Serious accident at work, home, or during recreational activity*
  • 5. Please indicate all that apply for the following event: Exposure to toxic substance (for example, dangerous chemicals, radiation)*
  • 6. Please indicate all that apply for the following event: Physical assault (for example, being attacked, hit, slapped, kicked, beaten up)*
  • 7. Please indicate all that apply for the following event: Assault with a weapon (for example, being shot, stabbed, threatened with a knife, gun, bomb)*
  • 8. Please indicate all that apply for the following event: Sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm)*
  • 9. Please indicate all that apply for the following event: Other unwanted or uncomfortable sexual experience*
  • 10. Please indicate all that apply for the following event: Combat or exposure to a war-zone (in the military or as a civilian)*
  • 11. Please indicate all that apply for the following event: Captivity (for example, being kidnapped, abducted, held hostage, prisoner of war)*
  • 12. Please indicate all that apply for the following event: Life-threatening illness or injury*
  • 13. Please indicate all that apply for the following event: Severe human suffering*
  • 14. Please indicate all that apply for the following event: Sudden violent death (for example, homicide, suicide)*
  • 15. Please indicate all that apply for the following event: Sudden accidental death*
  • 16. Please indicate all that apply for the following event: Serious injury, harm, or death you caused to someone else*
  • 17. Please indicate all that apply for the following event: Any other very stressful event or experience*
  • Should be Empty: