After completing this questionnaire, you'll be able to:
Email directly to Dr. Shah - Click a button to open your email app with pre-filled details
Download and send yourself - Download the results file and email it to: [email protected]
Important Notice:
This questionnaire is for information gathering purposes only and is not diagnostic. The responses you provide will be reviewed by your clinician as part of a comprehensive clinical assessment. Only a qualified healthcare professional can make diagnostic or treatment decisions. Please answer honestly based on your actual childhood experiences.
Privacy: All data is processed locally on your device. Nothing is sent anywhere until you choose to download and share your results file with your clinician.
📝 Answering Questions: You may leave questions blank if you're unsure or they don't apply to you. Don't guess - skipped items will be excluded from score calculations. However, try to answer as many as you can for accurate results.
0 of 45 items answered (45 skipped) (0%)
Your Information
Childhood Experiences and Feelings
Instructions: Think back to when you were before age 12 and answer as best you can remember. Rate how much each item describes you as a child.
0 = Not at all / Very slightly1 = Mildly2 = Moderately3 = Quite a bit4 = Very much
0 of 45 items answered (45 skipped) (0%)
✓ Latest response recorded
✓ Questionnaire Complete
Thank you for completing this questionnaire
Your responses have been saved. Please send your results to Dr. Shah using one of the options below.
Send Results to Dr. Shah:
Option 1: Click "Email Results" to open your email app with everything pre-filled. Just attach the file and send. Option 2: Download the file and email it to [email protected] yourself.