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Adverse Childhood Experience (ACE) Questionnaire
Name (First name, middle initial, and last name)*
Today's Date*
Student ID Number*
Date of Birth*
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?
OR
act in a way that made you afraid that you might be physically hurt?
Yes
No
2. 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
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?
OR
try to or actually have oral, anal, or vaginal sex with you?
Yes
No
4. 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
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?
OR
your parents were too drunk or high to take care of you or take you to the doctor if you needed?
Yes
No
6. Were your parents ever separated or divorced?
Yes
No
7. Was your parent or guardian...
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
ADDITIONAL QUESTIONS:
8. Did you live with anyone who was a problem drinker or alcoholic or who used
street drugs?
Yes
No
9. Was a household member depressed or mentally ill or did a household member
attempt suicide?
Yes
No
10. Did a household member go to prison?
Yes
No