Adverse Childhood Experience (ACE) Questionnaire
Sign in to Google to save your progress. Learn more
Email *
Name *
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 you? Did they act in a way that made you afraid that you might be physically hurt?
 *
 2. Did a parent or other adult in the household often push, grab, slap, or throw something at you? Did they ever hit you so hard that you had marks or were injured?
 *
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? Did they try to or actually have oral, anal, or vaginal sex with you?
 *
4. Did you often feel that no one in your family loved you or thought you were important or special? Did you often feel as your family didn’t look out for each other, feel close to each other, or support each other?
 *
 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? Did you often feel that your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
 *
6. Were your parents ever separated or divorced?
 *
7. Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Was she 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?
 *
8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
 *
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
 *
10. Did a household member go to prison?
 *
Now add up your “Yes” answers and enter the total below:
 *

That number is your ACE Score. Responses and Scores will be discussed during intake session(s).

Source: CDC-Kaiser Permanente ACE Study, 1998.


Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms