Print: Adverse Child Events Questionnaire

ACEs (adapted from    

From birth to eighteen years old, did you experience any of the following:

Were you often sworn at, insulted, put down, or humiliated? Or did an adult act in a way that made you afraid that you might be physically hurt? Yes No
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? Yes No
Did someone 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? Yes No
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? Yes No
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? Yes No
Were your parents ever separated or divorced? Yes No
Was a parent often pushed, grabbed, slapped, or had something thrown at them?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?

Yes No
Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Yes No
Was a household member depressed or mentally illor did a household member attempt suicide? Yes No
Did a household member go to prison? Yes No