ACE Questionnaire

First Name*

(Needed for Sorting)

First 4 Letters of Last Name*

(Needed for Sorting)

Telephone Number*

Client's Full name*

Adverse Childhood Experience (ACE) Questionnaire Finding your ACE Score

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

1. Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate OR Act in a way that made you afraid that you might be physically hurt?*

YesNo

If yes enter 1

2. 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

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 Try to or actually have oral, anal, or vaginal sex with you?*

YesNo

If yes enter 1

4. Did you often feel that no one in your family loved you or thought you were important or special? OR You family didn't look out for each other, feel close to each other, or support each other?*

YesNo

If yes enter 1

5. 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

6. Were your parents ever separated or divorced?*

YesNo

If yes enter 1

7. Was your mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? 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

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?*

YesNo

If yes enter 1

9. Was a household member depressed or mentally ill or did a household member attempt suicide?*

YesNo

If yes enter 1

10. Did a household member go to prison?*

YesNo

If yes enter 1

Total of all "Yes" answers*

ADULTS ONLY