Trauma Symptom Checklist

Trauma Symptom Checklist - 40
Client Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Today's Date*

MonthDayYear
Date
Staff Name*
Stage of Treatment*

New ClientDuring TreatmentEnd of Treatment
How often have you experienced each of the following in the last month? Please read the symptom listed then answer 0-3, 0 being the least often and 3 being the most often. (Briere & Runtz, 1989)
1. Headaches*

0 (Never)123 (Often)
2. Insomnia*

0 (Never)123 (Often)
3. Weight loss (without dieting)*

0 (Never)123 (Often)
4. Stomach problems*

0 (Never)123 (Often)
5. Sexual problems*

0 (Never)123 (Often)
6. Feeling isolated from others*

0 (Never)123 (Often)
7. "Flashbacks" (sudden, vivid, distracting memories)*

0 (Never)123 (Often)
8. Restless sleep*

0 (Never)123 (Often)
9. Low sex drive*

0 (Never)123 (Often)
10. Anxiety Attacks*

0 (Never)123 (Often)
11. Sexual overactivity*

0 (Never)123 (Often)
12. Loneliness*

0 (Never)123 (Often)
13. Nightmares*

0 (Never)123 (Often)
14. "Spacing out" (going away in your mind)*

0 (Never)123 (Often)
15. Sadness*

0 (Never)123 (Often)
16. Dizziness*

0 (Never)123 (Often)
17. Not feeling satisfied with your sex life*

0 (Never)123 (Often)
18. Trouble controlling your temper*

0 (Never)123 (Often)
19. Waking up early in the morning*

0 (Never)123 (Often)
20. Uncontrollable crying*

0 (Never)123 (Often)
21. Fear of men*

0 (Never)123 (Often)
22. Not feeling rested in the morning*

0 (Never)123 (Often)
23. Having sex that you didn't enjoy*

0 (Never)123 (Often)
24. Trouble getting along with others*

0 (Never)123 (Often)
25. Memory problems*

0 (Never)123 (Often)
26. Desire to physically hurt yourself*

0 (Never)123 (Often)
27. Fear of women*

0 (Never)123 (Often)
28. Waking up in the middle of the night*

0 (Never)123 (Often)
29. Bad thoughts or feelings during sex*

0 (Never)123 (Often)
30. Passing out*

0 (Never)123 (Often)
31. Feeling that things are "unreal"*

0 (Never)123 (Often)
32. Unnecessary or over-frequent washing*

0 (Never)123 (Often)
33. Feeling of inferiority*

0 (Never)123 (Often)
34. Feeling tense all the time*

0 (Never)123 (Often)
35. Being confused about your sexual feelings*

0 (Never)123 (Often)
36. Desire to physically hurt others*

0 (Never)123 (Often)
37. Feelings of guilt*

0 (Never)123 (Often)
38. Feeling that you are not always in your body*

0 (Never)123 (Often)
39. Having trouble breathing*

0 (Never)123 (Often)
40. Sexual feelings when you shouldn't have them*

0 (Never)123 (Often)
Dissociation Score
Anxiety Score
Depression Score
SATI Score
Sleep Disturbance Score
Sexual Problems Score
Trauma Symptom Checklist – 40 (Briere & Runtz, 1989) Subscale composition and scoring for the TSC-40:

The score for each subscale is the sum of the relevant items

Dissociation – 7, 14, 16, 25, 31, 38

Anxiety – 1, 4, 10, 16, 21, 27, 32, 34, 39

Depression – 2, 3, 9, 15, 19, 20, 26, 33, 37

SATI (Sexual Abuse Trauma Index) – 5, 7, 13, 21, 25, 29, 31

Sleep Disturbance – 2, 8, 13, 19, 22, 28

Sexual Problems – 5, 9, 11, 17, 23, 29, 35, 40

TSC Total Score: 1-40

Important Note: This measure assesses trauma-related problems in seceral categories. According to John Briere, PhD “The TSC-40 is a research instrument only. Use of this scale is limited to professional researchers. It is not intended as, nor should it be used as, a self-test under any circumstances.” For a more current version of the measure, which can be used for clinical purposes (and for which there is a fee), consider the Trauma Symptom Inventory – contact Psychological Assessment Resources at 800-331-8378. The TSC-40 is freely available to researchers. No additional permission is required for use or reproduction of this measure, although the following citation is needed: Briere, J.N. & Runtz, M.G. (1989). The Trauma Symptom Checklist (TSC-33): Early data on a new scale. Journal of Interpersonal Violence, 4, 151-163. For further information on the measure, go to www.johnbriere.com.
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Trauma Symptom Checklist - 40

How often have you experienced each of the following in the last month? Please read the symptom listed then answer 0-3, 0 being the least often and 3 being the most often. (Briere & Runtz, 1989)