ACE Questionnaire

ACE Questionnaire

Adverse Childhood Experience
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
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?*

YESNO
If YES, ENTER 1
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?*

YESNO
If YES, ENTER 1
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 Try to or actually have oral, anal, or vaginal sex with you?*

YESNO
If YES, ENTER 1
Did you 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 each other, feel close to each other, or support each other?*

YESNO
If YES, ENTER 1
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?*

YESNO
If YES, ENTER 1
Were your parents ever separated or divorced?*

YESNO
If YES, ENTER 1
Was your mother or stepmother...
Often pushed, grabbed, slapped, or had something thrown at her? OR 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?*

YESNO
If YES, ENTER 1
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*

YESNO
If YES, ENTER 1
Was a household member depressed or mentally ill or did a household member attempt suicide?*

YESNO
If YES, ENTER 1
Did a household member go to prison?*

YESNO
If YES, ENTER 1
Now ADD UP your "YES" answers. This is your ACE Score.
Should be Empty:

ACE Questionnaire

While you were growing up, during your first 18 years of life...