Pediatric ACEs and Related Life Events Screener

Many families experience stressful life events. Over time these experiences can affect your child’s health and wellbeing. We would like to ask you questions about your child so we can help them be as healthy as possible.

CHILD - To be completed by: Caregiver

At any point in time since your child was born, has your child seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

1.Has your child ever lived with a parent/caregiver who went to jail/prison?

2.Do you think your child ever felt unsupported, unloved and/or unprotected?

3.Has your child ever lived with a parent/caregiver who had mental health issues?

(for example, depression, schizophrenia, bipolar disorder , PTSD, or an anxiety disorder)

4.Has a parent/caregiver ever insulted, humiliated, or put down your child?

5.Has the child’s biological parent or any caregiver ever had, or currently has a problem with

too much alcohol, street drugs or prescription medications use?

6.Has your child ever lacked appropriate care by any caregiver?

(for example, not being protected from unsafe situations, or not cared for when sick or

injured even when the resources were available)

7.Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted

or humiliated by another adult?

Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched

beaten up or hurt with a weapon?

8.Has any adult in the household often or very often pushed, grabbed, slapped or thrown

Or has any adult in the household ever hit your child so hard that your child had marks or

Or has any adult in the household ever threatened your child or acted in a way that made

your child afraid that they might be hurt?

9.Has your child ever experienced sexual abuse?

(for example, anyone touched your child or asked your child to touch that person in a way

that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)

Have there ever been significant changes in the relationship status of the child’s

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Child (Parent/Caregiver Report) – Deidentified

1.Has your child ever seen, heard, or been a victim of violence in your neighborhood,

(for example, targeted bullying, assault or other violent actions, war or terrorism)

2.Has your child experienced discrimination?

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

3.Has your child ever had problems with housing?

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

4.Have you ever worried that your child did not have enough food to eat or that the food for

your child would run out before you could buy more?

5.Has your child ever been separated from their parent or caregiver due to foster care, or

6.Has your child ever lived with a parent/caregiver who had a serious physical illness or

7.Has your child ever lived with a parent or caregiver who died?

This tool was created in partnership with UCSF School of Medicine.

Child (Parent/Caregiver Report) – Deidentified

Pediatric ACEs and Related Life Events Screener

Many families experience stressful life events. Over time these experiences can affect your child’s health and wellbeing. We would like to ask you questions about your child so we can help them be as healthy as possible.

At any point in time since your child was born, has your child seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

Please check “Yes” where apply.

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

too much alcohol, street drugs or prescription medications use?

(for example, not being protected from unsafe situations, or not cared for when sick or

injured even when the resources were available)

or humiliated by another adult?

Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched

beaten up or hurt with a weapon?

Or has any adult in the household ever hit your child so hard that your child had marks or

Or has any adult in the household ever threatened your child or acted in a way that made

your child afraid that they might be hurt?

(for example, anyone touched your child or asked your child to touch that person in a way

that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Child (Parent/Caregiver Report) – Identified

Please check “Yes” where apply.

(for example, targeted bullying, assault or other violent actions, war or terrorism)

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

your child would run out before you could buy more?

This tool was created in partnership with UCSF School of Medicine.

Child (Parent/Caregiver Report) – Identified

Pediatric ACEs and Related Life Events Screener

Many families experience stressful life events. Over time these experiences can affect your child’s health and wellbeing. We would like to ask you questions about your child so we can help them be as healthy as possible.

CHILD - To be completed by: Caregiver

At any point in time since your child was born, has your child seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

1.Has your child ever lived with a parent/caregiver who went to jail/prison?

2.Do you think your child ever felt unsupported, unloved and/or unprotected?

3.Has your child ever lived with a parent/caregiver who had mental health issues?

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

4.Has a parent/caregiver ever insulted, humiliated, or put down your child?

5.Has the child’s biological parent or any caregiver ever had, or currently has a problem with

too much alcohol, street drugs or prescription medications use?

6.Has your child ever lacked appropriate care by any caregiver?

(for example, not being protected from unsafe situations, or not cared for when sick or

injured even when the resources were available)

7.Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted

or humiliated by another adult?

Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched

beaten up or hurt with a weapon?

8.Has any adult in the household often or very often pushed, grabbed, slapped or thrown

Or has any adult in the household ever hit your child so hard that your child had marks or

Or has any adult in the household ever threatened your child or acted in a way that made

your child afraid that they might be hurt?

9.Has your child ever experienced sexual abuse?

(for example, anyone touched your child or asked your child to touch that person in a way

that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)

Have there ever been significant changes in the relationship status of the child’s

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Child (Parent/Caregiver Report) – Deidentified

Please check “Yes” where apply.

1.Has your child ever seen, heard, or been a victim of violence in your neighborhood,

2.Has your child experienced discrimination?

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

3.Has your child ever had problems with housing?

times in a six-month period, faced eviction or foreclosure, or had to live with multiple

4.Have you ever worried that your child did not have enough food to eat or that the food for

5.Has your child ever been separated from their parent or caregiver due to foster care, or

6.Has your child ever lived with a parent/caregiver who had a serious physical illness or

This tool was created in partnership with UCSF School of Medicine.

Child (Parent/Caregiver Report) – Identified

Pediatric ACEs and Related Life Events Screener

Many families experience stressful life events. Over time these experiences can affect your child’s health and wellbeing. We would like to ask you questions about your child so we can help them be as healthy as possible.

TEEN (Parent/Caregiver Report) - To be completed by: Caregiver

At any point in time since your child was born, has your child seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

1.Has your child ever lived with a parent/caregiver who went to jail/prison?

2.Do you think your child ever felt unsupported, unloved and/or unprotected?

Has your child ever lived with a parent/caregiver who had mental health issues?

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

Has a parent/caregiver ever insulted, humiliated, or put down your child?

Has the child’s biological parent or any caregiver ever had, or currently has a problem with

too much alcohol, street drugs or prescription medications use?

Has your child ever lacked appropriate care by any caregiver?

(for example, not being protected from unsafe situations, or not cared for when sick or

injured even when the resources were available)

Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted

or humiliated by another adult?

Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched

beaten up or hurt with a weapon?

Has any adult in the household often or very often pushed, grabbed, slapped or thrown

Or has any adult in the household ever hit your child so hard that your child had marks or

Or has any adult in the household ever threatened your child or acted in a way that made

your child afraid that they might be hurt?

Has your child ever experienced sexual abuse?

(for example, anyone touched your child or asked your child to touch that person in a way

that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)

Have there ever been significant changes in the relationship status of the child’s

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Teen (Parent/Caregiver Report) – Deidentified

Has your child ever seen, heard, or been a victim of violence in your neighborhood,

(for example, targeted bullying, assault or other violent actions, war or terrorism)

Has your child experienced discrimination?

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

Has your child ever had problems with housing?

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

Have you ever worried that your child did not have enough food to eat or that the food for

your child would run out before you could buy more?

Has your child ever been separated from their parent or caregiver due to foster care, or

Has your child ever lived with a parent/caregiver who had a serious physical illness or

Has your child ever lived with a parent or caregiver who died?

Has your child ever been detained, arrested or incarcerated?

Has your child ever experienced verbal or physical abuse or threats from a romantic

(for example, a boyfriend or girlfriend)

This tool was created in partnership with UCSF School of Medicine.

Teen (Parent/Caregiver Report) – Deidentified

Pediatric ACEs and Related Life Events Screener

Many families experience stressful life events. Over time these experiences can affect your child’s health and wellbeing. We would like to ask you questions about your child so we can help them be as healthy as possible.

At any point in time since your child was born, has your child seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

Please check “Yes” where apply.

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

too much alcohol, street drugs or prescription medications use?

(for example, not being protected from unsafe situations, or not cared for when sick or

injured even when the resources were available)

or humiliated by another adult?

Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched

beaten up or hurt with a weapon?

Or has any adult in the household ever hit your child so hard that your child had marks or

Or has any adult in the household ever threatened your child or acted in a way that made

your child afraid that they might be hurt?

(for example, anyone touched your child or asked your child to touch that person in a way

that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Teen (Parent/Caregiver Report) - Identified

Please check “Yes” where apply.

(for example, targeted bullying, assault or other violent actions, war or terrorism)

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

your child would run out before you could buy more?

(for example, a boyfriend or girlfriend)

This tool was created in partnership with UCSF School of Medicine.

Teen (Parent/Caregiver Report) - Identified

Many families experience stressful life events. Over time these experiences can affect your health and wellbeing. We would like to ask you questions about your child so we can help you be as healthy as possible.

TEEN (Self-Report)- To be completed by: Patient

At any point in time since you were born, have you seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

Have you ever lived with a parent/caregiver who went to jail/prison?

2.Have you ever felt unsupported, unloved and/or unprotected?

Have you ever lived with a parent/caregiver who had mental health issues?

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

Has a parent/caregiver ever insulted, humiliated, or put you down?

Has your biological parent or any caregiver ever had, or currently has a problem with too

much alcohol, street drugs or prescription medications use?

Have you ever lacked appropriate care by any caregiver?

(for example, not being protected from unsafe situations, or not being cared for when sick

or injured even when the resources were available)

Have you ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or

Or have you ever seen or heard a parent/caregiver being slapped, kicked, punched beaten

Has any adult in the household often or very often pushed, grabbed, slapped or thrown

Or has any adult in the household ever hit you so hard that you had marks or were injured?

Or has any adult in the household ever threatened you or acted in a way that made you

afraid that you might be hurt?

Have you ever experienced sexual abuse?

(for example, has anyone touched you or asked you to touch that person in a way that was

unwanted, or made you feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with you)

Have there ever been significant changes in the relationship status of your caregiver(s)?

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Teen (Self Report) - Deidentified

Have you ever seen, heard, or been a victim of violence in your neighborhood, community

(for example, targeted bullying, assault or other violent actions, war or terrorism)

Have you experienced discrimination?

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

Have you ever had problems with housing?

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

Have you ever worried that you did not have enough food to eat or that food would run out

before you or your parent/caregiver could buy more?

Have you ever been separated from your parent or caregiver due to foster care, or

Have you ever lived with a parent/caregiver who had a serious physical illness or

Have you ever lived with a parent or caregiver who died?

Have you ever been detained, arrested or incarcerated?

Have you ever experienced verbal or physical abuse or threats from a romantic partners?

(for example, a boyfriend or girlfriend)

This tool was created in partnership with UCSF School of Medicine.

Teen (Self Report) - Deidentified

Pediatric ACES and Related Life Events Screener

Many families experience stressful life events. Over time these experiences can affect your health and wellbeing. We would like to ask you questions so we can help you be as healthy as possible.

At any point in time since you were born, have you seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

Please check “Yes” where apply.

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

much alcohol, street drugs or prescription medications use?

(for example, not being protected from unsafe situations, or not being cared for when sick

or injured even when the resources were available)

Or have you ever seen or heard a parent/caregiver being slapped, kicked, punched beaten

Or has any adult in the household ever hit you so hard that you had marks or were injured?

Or has any adult in the household ever threatened you or acted in a way that made you

afraid that you might be hurt?

(for example, has anyone touched you or asked you to touch that person in a way that was

unwanted, or made you feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with you)

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Teen (Self Report) - Identified

Please check “Yes” where apply.

(for example, targeted bullying, assault or other violent actions, war or terrorism)

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

before you or your parent/caregiver could buy more?

(for example, a boyfriend or girlfriend)

This tool was created in partnership with UCSF School of Medicine.

Teen (Self Report) - Identified

Many families experience stressful life events. Over time these experiences can affect your child’s health and wellbeing. We would like to ask you questions about your child so we can help them be as healthy as possible.

At any point in time since your child was born, has your child seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

1.Has your child ever lived with a parent/caregiver who went to jail/prison?

2.Do you think your child ever felt unsupported, unloved and/or unprotected?

Has your child ever lived with a parent/caregiver who had mental health issues?

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

Has a parent/caregiver ever insulted, humiliated, or put down your child?

Has the child’s biological parent or any caregiver ever had, or currently has a problem with

too much alcohol, street drugs or prescription medications use?

Has your child ever lacked appropriate care by any caregiver?

(for example, not being protected from unsafe situations, or not cared for when sick or

injured even when the resources were available)

Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted

or humiliated by another adult?

Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched

beaten up or hurt with a weapon?

8.Has any adult in the household often or very often pushed, grabbed, slapped or thrown

Or has any adult in the household ever hit your child so hard that your child had marks or

Or has any adult in the household ever threatened your child or acted in a way that made

your child afraid that they might be hurt?

Has your child ever experienced sexual abuse?

(for example, anyone touched your child or asked your child to touch that person in a way

that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with your child)

Have there ever been significant changes in the relationship status of the child’s

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in or out)

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Teen (Parent/Caregiver Report) - Deidentified

Please check “Yes” where apply.

(for example, targeted bullying, assault or other violent actions, war or terrorism)

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

your child would run out before you could buy more?

(for example, a boyfriend or girlfriend)

This tool was created in partnership with UCSF School of Medicine.

Teen (Parent/Caregiver Report) - Identified

Many families experience stressful life events. Over time these experiences can affect your health and wellbeing. We would like to ask you questions so we can help you be as healthy as possible.

TEEN (Self-Report)- To be completed by: Patient

At any point in time since you were born, have you seen or been present when the following experiences happened? Please include past and present experiences.

Please note, some questions have more than one part separated by “OR.” If any part of the

question is answered “Yes,” then the answer to the entire question is “Yes.”

1.Have you ever lived with a parent/caregiver who went to jail/prison?

2.Have you ever felt unsupported, unloved and/or unprotected?

Have you ever lived with a parent/caregiver who had mental health issues?

(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)

Has a parent/caregiver ever insulted, humiliated, or put you down?

Has your biological parent or any caregiver ever had, or currently has a problem with too

much alcohol, street drugs or prescription medications use?

Have you ever lacked appropriate care by any caregiver?

(for example, not being protected from unsafe situations, or not being cared for when sick

or injured even when the resources were available)

Have you ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or

Or have you ever seen or heard a parent/caregiver being slapped, kicked, punched beaten

Has any adult in the household often or very often pushed, grabbed, slapped or thrown

Or has any adult in the household ever hit you so hard that you had marks or were injured?

Or has any adult in the household ever threatened you or acted in a way that made you

afraid that you might be hurt?

9.Have you ever experienced sexual abuse?

(for example, has anyone touched you or asked you to touch that person in a way that was

unwanted, or made you feel uncomfortable, or anyone ever attempted or actually had oral, anal, or vaginal sex with you)

Have there ever been significant changes in the relationship status of your caregiver(s)?

(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in

Please continue to the other side for the rest of questionnaire

This tool was created in partnership with UCSF School of Medicine.

Teen (Self Report) - Deidentified

Please check “Yes” where apply.

(for example, targeted bullying, assault or other violent actions, war or terrorism)

(for example, being hassled or made to feel inferior or excluded because of their race,

ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)

(for example, being homeless, not having a stable place to live, moved more than two

times in a six-month period, faced eviction or foreclosure, or had to live with multiple families or family members)

before you or your parent/caregiver could buy more?

(for example, a boyfriend or girlfriend)

This tool was created in partnership with UCSF School of Medicine.

Teen (Self Report) - Identified