Adverse Childhood Experience Questionnaire for Adults

Adverse Childhood Experience Questionnaire for Adults
California Surgeon General’s Clinical Advisory Committee
The relationships and experiences we encounter throughout our lives can have a profound impact on our well-being and overall health. This includes experiences we may have had during our childhood that can continue to influence us in the present or in the future. It is not uncommon to face challenging experiences during childhood, and it is important to recognize that these experiences may shape our behaviors and thoughts as we grow and develop. By acknowledging the impact of these experiences, we can work towards healing and improving our overall health and well-being.

Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please place a checkmark next to each ACE category that you experienced prior to your 18 birthday. Your score will be
Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?Did you lose a parent through divorce, abandonment, death, or other reason?Did you live with anyone who was depressed, mentally ill, or attempted suicide?Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?Did you live with anyone who went to jail or prison?Did a parent or adult in your home ever swear at you, insult you, or put you down?Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?Did you feel that no one in your family loved you or thought you were special?Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?
Email*
example@example.com
Your ACE score is the total number of checked responses
Should be Empty: