Adverse Childhood Experience (ACE) Questionnaire Welcome to your Adverse Childhood Experience (ACE) Questionnaire Date Name Email Phone This Questionnaire will ask you some questions about events that happened during your childhood; specifically the first 18 years of your life. The information you provide by answering these questions will allow us to better understand problems that may have occurred early in your life and allow us to explore how those problems may be impacting the challenges you are experiencing today. This can be very helpful in the success of your treatment. 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?OrAct in a way that made you afraid that you might be physically hurt? Yes No None 2. Did a parent or other adult in the household often: Push, grab, slap, or throw something at you?OrEver hit you so hard that you had marks or were injured? Yes No None 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?OrAttempt or actually have oral, anal, or vaginal intercourse with you? Yes No None 4. Did you often feel that: No one in your family loved you or thought you were important or special?OrYour family didn’t look out for each other, feel close to each other, or support each other? Yes No None 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?OrYour parents were too drunk or high to take care of you or take you to the doctor if you needed it? Yes No None 6. Were your parents ever separated or divorced? Yes No None 7. Were any of your parents or other adult caregivers: Often pushed, grabbed, slapped, or had something thrown at them?OrSometimes or often kicked, bitten, hit with a fist, or hit with something hard?OrEver repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes No None 8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs? Yes No None 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No None 10. Did a household member go to prison? Yes No None Time's up Leave a Reply Cancel replyCommentEnter your name or username to comment Enter your email address to comment Enter your website URL (optional) Save my name, email, and website in this browser for the next time I comment.
