Adverse Childhood Experiences (ACE) Questionnaire Welcome to your Adverse Childhood Experiences (ACE) QuestionnaireDid 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 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 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 Did you often feel that no one in your family loved you or thought you were important or special OR that 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 your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her 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 ill or did a household member attempt suicide? Yes No Did a household member go to prison? Yes No Time's up
