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Childhood Trauma Survey Questions Template

Childhood Trauma Survey Questions Template is designed by experts. This questionnaire is designed to carry questions that helps a researcher identify, if a person has experienced any childhood trauma during the growing up years and what exactly is that trauma. There are 11+ questions in this sample survey template that will help collect detailed information regarding childhood trauma experienced by an individual. This form can be customized and more questions can be added to suit the research needs. You can use this questionnaire with young adults and grown-ups to find about their history regarding child abuse/trauma.


What is your Gender?

Which age bracket do you fall in?

Please select your ethnicity.
Please select your marital status.
Do you have kids?

Did your parents often abuse you?
Did you lose a parent(s) during your childhood?
During your childhood did your witness your mother or any other female member of the family being abused?
Did any of your family member go to jail, when you were a kid?

If Yes, then please select which family member of yours went to the jail.

Is there any specific incident from your childhood that had a deep impact on you, that you would like to share?

Why Conduct Childhood Trauma Survey?

  • A child may not be able to describe a traumatic experience.
  • A childhood trauma questionnaire can help in understanding what the kid might have gone through.
  • Equipped with some fundamental psychological questions to begin with, might help an adult or a trained professional understand the child’s current state of mind.
  • Also visual questions or drawing exercises will shed some light on a traumatic incident the child might have faced.
  • A brief survey can be instrumental in identifying and analysing childhood trauma.

What is Childhood Trauma?

Children are born innocent and childhood is known as a blank/white paper which gets written over time with lots of memories and experiences. We all have good and bad memories of childhood. Memories remind us about our past a lot of times. Happy moments of our children could be anything. It could be your birthday gift, chocolates, bicycle, day out with your parents etc.

Whereas childhood trauma are bad memories and experiences. It can be defined as mental or physical negative experiences of childhood which may affect your future and future course of action. It leads to anger, stress, mental or physical illness, loss of self-confidence etc.

Childhood trauma can also be classified into :

  • Trauma due to loss of family member/s,
  • Separation from parents and
  • Child abuse

Probable Reasons of Childhood Trauma

  • A sudden death of a person in the family who’s very much attached to a child may give him/her trauma.
  • Child sexual abuse cases are on the rise these days. Which often happens at the hands of a trusted person. This is the main cause of childhood trauma. It creates a negative impact in the society.
  • Parents must be vigilant and sensitive to their children to prevent them from this. Kids should be made aware of the real issue and be taught to be smart to protect themselves.

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