Any traumatic event during childhood or an extreme event at any point of time in one’s life can lead to acute stress disorder that leaves a lasting impression on a person’s mind. Acute Stress Questionnaire helps one to revisit any such experiences and take the fear out of the person’s mind and make him or her normal again.

Acute Stress Disorder Questionnaire Sample:

Name:                       ____________________

Address:            ____________________

Phone Number:   ____________________

Email id:            ____________________

Q1. Have you come across any tragic event in your family in your life?

a)   Yes

b)   No

Q2. Have you been exposed to extreme events in your childhood?

a)   Yes

b)   No

If ‘Yes’, describe the event ____________________________________________

Q3. Did you ever watch a horror serial or movie that has had a lasting effect on you?

a)   Yes

b)   No

If ‘Yes’, then are you still horrified with the same? Yes / No

Q4. What kind of treatment do your parents show / have shown in the past?

a)   Caring and pampering

b)   Indifferent

c)   Overcautious and possessive

d)   Others _______________________________________________

Q5. Did you or any of your family members have faced sexual harassment?

a)   Yes

b)   No

Q6. Do you face sleep disorders or unpleasant dreams?

a)   Yes

b)   No

Q7. Were your earlier relationships traumatic?

a)   Always

b)   Never

c)   Sometimes

Q8. How often do you meet and interact with friends?

a)   At least once in a month

b)   At least once in a fortnight

c)   Every week

d)   Very rarely

Q9. If you have experienced any disturbing event, then choose whom you have shared your experience with

a)   Family

b)   Friends

c)   Colleagues

d)   All

e)   None