Early Trauma Inventory Form – Fill Out and Use This PDF

The Early Trauma Inventory Self Report-Short Form (ETISR-SF) is a comprehensive tool designed by J. Douglas Bremner from Emory University School of Medicine, Atlanta GA, aimed at identifying experiences of trauma occurring before the age of 18. It encompasses various types of adverse experiences, ranging from natural disasters, serious accidents, illnesses, family troubles, to encounters with violence and abuse. By meticulously evaluating early life traumas, individuals, and clinicians can gain insights into the profound impact these events may have on well-being and development. Consider completing the form by clicking the button below to facilitate a deeper understanding of early traumas and their long-lasting effects.

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Early Trauma Inventory Form PDF Details

The Early Trauma Inventory Self Report-Short Form (ETISR-SF) serves as a critical tool created by Dr. J. Douglas Bremner from Emory University School of Medicine in Atlanta, Georgia, to gauge the range and depth of trauma experiences individuals have encountered before the age of 18. By carefully compiling a series of questions divided into four primary categories—General Traumas, Physical Punishment, Emotional Abuse, and Sexual Events—the form endeavors to meticulously outline the participant's exposure to potentially life-altering events. From grappling with the devastation of natural disasters to enduring the pains of physical and emotional maltreatment, this inventory spans a broad spectrum of traumatic experiences. Furthermore, it probes into the complex arena of early sexual encounters, whether consensual or forced, shedding light on sensitive issues often shrouded in silence. Participants are asked to reflect not only on the occurrence of these experiences but also on the profound emotional and psychological impacts they may have engendered, with a distinct focus on feelings of fear, alienation, or helplessness. This detailed self-reporting mechanism acts as a gateway to understanding the cascading effects of early traumas on an individual's mental and emotional well-being, paving the way for targeted therapeutic interventions and support mechanisms.

Question	Answer
Form Name	Early Trauma Inventory Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	trauma inventory report, early trauma inventory questionnaire, early trauma inventory report, trauma inventory self report form

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Early Trauma Inventory Self Report-Short Form (ETISR-SF)

J. Douglas Bremner, Emory University School of Medicine, Atlanta GA

Participant Name or ID:_____________________ DOB:_______ Age:____ Assessment Date:__________

Part 1. General Traumas. Before the age of 18

1.	Were you ever exposed to a life-threatening natural disaster?	YES	NO
2.	Were you involved in a serious accident?	YES	NO
3.	Did you ever suffer a serious personal injury or illness?	YES	NO
4.	Did you ever experience the death or serious illness of a parent or a primary
	caretaker?	YES	NO
5.	Did you experience the divorce or separation of your parents?	YES	NO
6.	Did you experience the death or serious injury of a sibling?	YES	NO
7.	Did you ever experience the death or serious injury of a friend?	YES	NO
8.	Did you ever witness violence towards others, including family members?	YES	NO
9.	Did anyone in your family ever suffer from mental or psychiatric illness or have a
	a “breakdown”?	YES	NO
10.	Did your parents or primary caretaker have a problem with alcoholism or
	drug abuse?	YES	NO
11.	Did you ever see someone murdered?	YES	NO

Part 2. Physical Punishment. Before the age of 18

1.	Were you ever slapped in the face with an open hand?	YES	NO
2.	Were you ever burned with hot water, a cigarette or something else?	YES	NO
3.	Were you ever punched or kicked?	YES	NO
4.	Were you ever hit with an object that was thrown at you?	YES	NO
5.	Were you ever pushed or shoved?	YES	NO

Part 3. Emotional Abuse. Before the age of 18

1.	Were you often put down or ridiculed?	YES	NO
2.	Were you often ignored or made to feel that you didn’t count?	YES	NO
3.	Were you often told you were no good?	YES	NO
4.	Most of the time were you treated in a cold, uncaring way or made to feel like you
	were not loved?	YES	NO
5.	Did your parents or caretakers often fail to understand you or your needs?	YES	NO

Part 4. Sexual Events. Before the age of 18

1.	Were you ever touched in an intimate or private part of your body (e.g. breast,
	thighs, genitals) in a way that surprised you or made you feel uncomfortable?	YES	NO
2.	Did you ever experience someone rubbing their genitals against you?	YES	NO
3.	Were you ever forced or coerced to touch another person in an intimate or private
	part of their body?	YES	NO
4.	Did anyone ever have genital sex with you against your will?	YES	NO
5.	Were you ever forced or coerced to perform oral sex on someone against your will?. YES		NO
6.	Were you ever forced or coerced to kiss someone in a sexual rather than an
	affectionate way?	YES	NO

If you responded “YES” for any of the above events, answer the following for the one that has had the greatest impact on your life. In answering consider how you felt at the time of the event.

1.	Did you experience emotions of intense fear, horror or helplessness?	YES	NO
2.	Did you feel out-of-your-body or as if you were in a dream?	YES	NO

REVISED ON 3/09

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Early Trauma Inventory Form – Fill Out and Use This PDF

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