Template library · Assessments & screeners
Trauma History Screen template
Ask about lifetime exposure to potentially traumatic events. Client may decline to answer any item.
Structured trauma exposure history
- 23 fields across 4 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
Assessment Details
- Client NameText
- Date of BirthDate
- Client ID / MRNText
- Date of AssessmentDate
- Clinician / CoachText
- Location / ModalityText
Exposure History
- Serious accident or injuryTick box
- Natural disasterTick box
- Physical assaultTick box
- Sexual assault or abuseTick box
- Combat or war-zone exposureTick box
- Witnessed violenceTick box
- Sudden death of a loved oneTick box
- Life-threatening illnessTick box
- Childhood neglect or abuseTick box
- Other significant traumaTick box
Clinical Notes
- Age at first exposureText
- Current symptoms related to identified eventsText
- Prior treatment for trauma-related symptomsText
Signatures
- Clinician SignatureSignature
- Date signed (clinician)Date
- Client SignatureSignature
- Date signed (client)Date
When to use it
Use an assessment at the start of work to set a baseline, then repeat it at review points so you and the client can see what has changed.
How it works in MyWellOps
- Pick it from Documents.
- Send it to the client to complete, or fill it in together during a session.
- Each completed copy is kept on the client’s record, so earlier results are there to compare.
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