top of page

For each question below circle how you have felt during the past week.


0 = Not At All 4 = Very Much

Do you have pains in your lower back?
Do you feel blocked in getting things done?
Do you feel shy or uneasy with the opposite sex?
Do you feel lonely?
Do you feel nervous or shaky inside?
Do you have temper outbursts you cannot control?
Are you afraid in open spaces or on the streets?
Do you feel that most people cannot be trusted?
Do you feel that others can control your thoughts?
Do you experience soreness in your muscles?

© 2024 by Christine Poje TraumaTherapyAmerica

bottom of page