Adverse Childhood Experience
Name
*
First Name
Last Name
1. Did a parent or other adult in the household often: (a.) Swear at you, insult you, put, you down, or humiliate you? or (b.) Act in a way that made you feel afraid
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Yes
No
2. Did a parent or other adult in the household often: (a.) Push, grab, slap, or throw something at you? or (b.) Ever hit you so hard that you had marks or were injured?
*
Yes
No
3. Did an adult or person at least 5 years older than you ever: (a.) Touch or fondle you or have you touch their body in a sexual way?or (b.) Try to or actually have oral, anal, or vaginal sex with you?
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Yes
No
4. Did you often feel that: (a.) No one in your family loved you or thought you were important or special? or (b.) Your family didn't look out for each other, feel close to each other, -0r support each other?
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Yes
No
5. Did you often feel that: (a.) You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? or (b.) Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
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Yes
No
6. Were your parents ever separated or divorced?
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Yes
No
7. Was your mother or stepmother: (a.) Often pushed, grabbed, slapped, or had something thrown at her? or (b.) Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or (c.) Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
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Yes
No
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
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Yes
No
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
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Yes
No
10. Did a household member go to prison?
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Yes
No
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