• Ace Survey

    This form will take approximately 5 minutes to complete.
  • Date
     - -

  • When you were growing up, during the first 18 years of life:

    Please fill in the appropriate information as best you can.
  • 1. Did a parent or other adult in the household often or very 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?*
  • 2. Did a parent or other adult in the household: Often or very often push, grab, slap or throw something at you? - or - Ever hit you so hard that you had marks or were injured?*
  • 3. 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 - Attempt or actually have oral, anal, or vaginal intercourse with you?*
  • 4. Did you often or very often feel that: No one in your family loved you or thought you were important or special? - or - Your family didn’t look out for, feel close to, or support each other?*
  • 5. Did you often or very 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?*
  • 6. Were your parents ever separated or divorced?*
  • 7. Did your mother or stepmother: Often or very often pushed, grabbed, slapped or had something thrown at her? - or - Sometimes, often, or very often kicked, bitten, hit with a fist or hit with something hard? - or - Ever repeatedly hit at least a few minutes or threatened with a gun or knife?*
  • 8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*
  • 9. Was a household member depressed or mentally ill, or did a household member attempt suicide?*
  • 10. Did a household member go to prison?*
  • Date
     - -
  • Should be Empty: