ACE Questionnaire
Adverse Childhood Experience - Finding your ACE Score
First Name
*
Last Name
*
Date of Birth:
*
Age
*
While you were growing up, during your first 18 years of life:
Did a parent or other adult in the household often swear at you, insult you, put you down or humiliate you? Or, act in a way that made you afraid that you might be physically hurt?
Yes
No
Did a parent or other adult in the household often push, grab, slap or throw something at you? Or, ever hit you so hard that you had marks or were injured?
Yes
No
Did an adult or person at least 5 years older than you EVER touch or fondle you or have you touch their body in a sexual way? Or, tried to or actually had oral, anal or vaginal sex with you?
Yes
No
Did you often feel that no one in your family loved you or though you were important or special? Or, your family didn't look out for each other, feel close to each other or support each other?
Yes
No
Did you often feel that you didn't have enough to eat, had to wear dirty clothes and had no one to protect you? Or, your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
Yes
No
Were your parents ever separated or divorced?
Yes
No
Was your mother or stepmother often pushed, grabbed, slapped or had something thrown at her? sometimes or often kicked, bitten, hit with a fist or hit with something hard? Or ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes
No
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes
No
Was a household member depressed or mentally ill or did a household member attempt suicide?
Yes
No
Did a household member go to prison?
Yes
No
ACE Score - Total the number of "Yes" answers here:
Submit
Should be Empty: