Early Trauma Inventory Form PDF Details

The Early Trauma Inventory Form (ETI) is a measure designed to assess the occurrence and severity of traumatic events in childhood. The ETI was developed as a tool to aid in the diagnosis of post-traumatic stress disorder (PTSD) in adults, but may also be used to assess trauma exposure in children. The ETI consists of 15 questions which ask about different types of traumatic events, including physical abuse, sexual abuse, and witness to violence. It can be completed by the individual who experienced the trauma, or by someone else who is familiar with their history. The results of the ETI can help clinicians determine whether a person has been exposed to trauma and identify areas that may need further assessment.

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 self report short form pdf conclusion process detailed (part 1)

2. Just after the first part is filled out, go to enter the relevant information in all these: Were you ever slapped in the face, Part Emotional Abuse Before the, Were you often put down or, Part Sexual Events Before the age, Were you ever touched in an, affectionate way YES NO, and If you responded YES for any of.

If you responded YES for any of, Were you ever touched in an, and Part Emotional Abuse Before the in early trauma inventory self report short form pdf

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Revised on, Did you experience emotions of, and Revised on in early trauma inventory self report short form pdf

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