Print: Adverse Child Events Questionnaire

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

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