Please approach all material with care. This material is not a substitute for usual healthcare.

Please be aware that if you are a parent yourself, this form may be stressful. If you yourself have had a difficult childhood, it almost certainly could make it more possible that your stress rubbed off on your children. This form is about understanding how trauma is passed over generations.

These forms don’t take into account ACEs from racism, sexism, ageism. and other forms of prejudice and injuries, for example those suffered by immigrants. Also the long term effects of childhood difficulties differ from person to person, and also whether there was support by another adult.

Your Childhood Experiences affect your life. If you feel in a safe place, complete this form. I would suggest you discuss adverse child events scores with your doctor or health care provider before completing the form, as it could trigger bad memories or even flashbacks.

The higher the number, the more adverse or difficult childhood experiences in your life, the more likely you are to have Complex PTSD.

ADVERSE CHILD EVENTS QUESTIONNAIRE

Below: Another form you can complete if you prefer more in-depth questions.

Form is for experiences up to the age of 18 years. Parents do the best they can. Many parents have had their own trauma. This form is not meant to judge your parents. Here parent also means guardian. Form copyright J. Dercksen

If something hurtful or bad happened to you, was it easy to turn to your parents for help and advice and did you feel safe even when you had done something wrong

0 – Always

1 – Most of the time

2 – I was afraid of being hurt if I did something wrong/ Or my parents were too occupied or upset sometimes to approach them

3 – I knew I would be hurt if my parents were angry with me OR I did not feel they cared about what I did even if it was wrong Or did I feel they just weren’t interested in what I did

Did your parents expect too much from you

0 – No. They were reasonable people and proud of me

1 – Their expectations were very high and it was difficult living up to them

2 – If I let them down, they became angry or said hurtful things to me

3 – I feel I let myself down OR they made me feel bad about myself and I have a low self image

Growing up did you feel important and special

0 – Yes

1 – a brother or sister was clearly a parent’s favorite

2 – a child or parent in the house was ill and needed extra care for a long time

3 – No. I didn’t feel important or special. Ora child died or was very ill needing much of my parent’s attention/ OR/ my parents didn’t seem to like any of their children or take an interest in us

Did an adult or sibling hurt you or scare you

0 – not at all

1 – sometimes a smack on the bottom

2 – sometimes a slap in the face or something similar Or I was ill and in hospital for more than a week

3 – Often hit. Once or more locked in a scary place Or Ever hit so hard you were injured or left with marks Or I was badly hurt in an accident or very ill that I thought I might die

Were you touched in a sexual way in a place other than your genitals even once

0 – Never

1 – By a person younger or slightly older (less than 5 years older) and I was able to say no or speak to my parents

2 – Enough to make me uncomfortable but I could leave

3 – Yes and I was unable to ask an adult for help or advice

Were you ever raped or had someone fondle your genitals

0 – Never

1 – Once fondled and I could speak to my parents

2 – Once fondled and I told no-one

3 – I was raped or had oral sex

Were your parents every separated or divorced. If a parent died before age 18 rate it as 3

0 – never

1 – No but they often fought and screamed at each other Or one parent was a way a lot

2 No But there was physical violence Or I often thought they should separate OR they seemed to separate lives

3 – yes OR One of my parents died before I was 18

Was your mother or father or guardian hurt by someone else living in the home

0 – never

1 – once or twice grabbed or pushed

2 – Once or twice hit or kicked or often had things thrown at them

3 – repeatedly hit or ever threatened with a gun or knife

Did you feel safe and protected growing up

0 – Yes

1 – Frequent parties at home made me uncomfortable OR sometimes I was hungry and couldn’t eat/refused food OR I was bullied at school but told my parents

2 – my parents drinking worried me OR I was bullied and no-one helped me Or A parent scared me

3 – Alcohol or drugs in the home made me feel unsafe / I left school because of bullying OR I was once placed in foster care Or I have generational trauma because I am a person of color or indigenous person OR one or both of my parents were very ill when I was growing up

How did you feel about the way your parents disciplined you

0 – My parents disciplined me in a reasonable way

1 – my parents were overprotective and I could often not do things that my friends; OR my parents were verbally abusive could

2 – I was rarely able to go out with friends after school or talk to them on the telephone/social media. And / Or my parents hit me / smacked me with their hands in places like my face. (not a small smack on the bottom)

3 -my parents let me do whatever I wanted Or were too busy to worry about me Or I had no close friends I could talk to at school OR My parents hit me at least once in a way that left a mark /bruise/ or with a belt or other object

Was there mental illness in the family when you were growing up

0 – No

1 – A parent had depression or anxiety

2 – a sibling had depression or anxiety or other emotional problems or addictions

3 – one of my parents was adopted/ a teenager ran away from home / purposelessly cut themselves Or a family member attempted suicide or went to prison OR a child died in the home

Were you adopted?

0 – No

1 –

2 – Yes but my biological mother is in my life and she never had a drug or alcohol problem

3 – Yes and my mother had a drug or alcohol problem or was suicidal

Childhood Experiences Form Score

Chronic Pain Management and Fibromyalgia

chronic pain management of fibromyalgia, back, arthritis and neuropathy pain

Childhood Experiences

Please approach all material with care. This material is not a substitute for usual healthcare.

Please be aware that if you are a parent yourself, this form may be stressful. If you yourself have had a difficult childhood, it almost certainly could make it more possible that your stress rubbed off on your children. This form is about understanding how trauma is passed over generations.

These forms don’t take into account ACEs from racism, sexism, ageism. and other forms of prejudice and injuries, for example those suffered by immigrants. Also the long term effects of childhood difficulties differ from person to person, and also whether there was support by another adult.

Your Childhood Experiences affect your life. If you feel in a safe place, complete this form. I would suggest you discuss adverse child events scores with your doctor or health care provider before completing the form, as it could trigger bad memories or even flashbacks.

The higher the number, the more adverse or difficult childhood experiences in your life, the more likely you are to have Complex PTSD.

ADVERSE CHILD EVENTS QUESTIONNAIRE

Total:

Please approach all material with care. This material is not a substitute for usual healthcare.

Please be aware that if you are a parent yourself, this form may be stressful. If you yourself have had a difficult childhood, it almost certainly could make it more possible that your stress rubbed off on your children. This form is about understanding how trauma is passed over generations.

These forms don’t take into account ACEs from racism, sexism, ageism. and other forms of prejudice and injuries, for example those suffered by immigrants. Also the long term effects of childhood difficulties differ from person to person, and also whether there was support by another adult.

Your Childhood Experiences affect your life. If you feel in a safe place, complete this form. I would suggest you discuss adverse child events scores with your doctor or health care provider before completing the form, as it could trigger bad memories or even flashbacks.

The higher the number, the more adverse or difficult childhood experiences in your life, the more likely you are to have Complex PTSD.

ADVERSE CHILD EVENTS QUESTIONNAIRE

Total:

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