Many children experience stressful life events that can affect their health and wellbeing. The results from this questionnaire will assist your child’s doctor in assessing their health and determining guidance. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided.

Please DO NOT mark or indicate which specific statements apply to you. 

Section 1. From birth until today…

▪ Have your parents or guardians separated or divorced
▪ Have you lived with a household member who served time in jail or prison
▪ Have you lived with a household member who was depressed, mentally ill or attempted suicide
▪ Have you seen or heard household members hurt or threaten to hurt each other
▪ A household member swore at, insulted, humiliated, or put you down in a way that scared you OR a household member acted in a way that made you afraid that s/he might be physically hurt
▪ Someone touched your private parts or asked you to touch their private parts in a sexual way
▪ More than once, you went without food, clothing, a place to live, or had no one to protect you
▪ Someone pushed, grabbed, slapped or threw something at you OR you were hit so hard that you were injured or had marks
▪ You lived with someone who had a problem with drinking or using drugs
▪ You often felt unsupported, unloved and/or unprotected

Section 2. From birth until today…

▪ Have you experienced or witnessed any violence while traveling to the USA
▪ Have you lived with a parent, guardian or close family member who died
▪ Have you been afraid of family members being deported or was separated from any family member due to
deportation
▪ Have you, or any family member, had any life-threatening medical conditions
▪ Have you been bullied or witnessed violence in the neighborhood or in school, current
neighborhood or in your home country
▪ Have you been treated badly because of race, sexual orientation, place of birth, disability, religion or immigration status