ACEs Questionnaire

Adverse Childhood Experiences (ACEs) Questionnaire

We invite you to participate in completing the ACEs Questionnaire that follows. It will take you about 10 minutes to complete. Completing the Questionnaire will assist service providers in learning more about the prevalence of ACEs in our service communities and how to better address these issues. To assist us in interpreting your ACEs responses in combination with others’ in the community, we need to know about you and your family. Please take a few moments to respond to the questions below. This information will be kept confidential and will only be used in combination with other respondents. After completing these questions, please go on to complete the ACEs Questionnaire.
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Adverse Childhood Experiences (ACEs) Questionnaire

The ACE questionnaire is a simple scoring system that attributes one point for each category of adverse childhood experience. The 10 questions below each cover a different domain of trauma, and refer to experiences that occurred prior to the age of 18. Higher scores indicate increased exposure to trauma, which have been associated with a greater risk of negative consequences. 

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As an adult, have you experienced any of the following (please check all that apply)

Are you under the regular care of a medical provider

What kind of medical insurance do you have?

What is your age?

What is your Sex

What is your ethnicity/race

What is your primary spoken language?

Please tell us how far you've gone in school(choose one)

What is your current marital status?

How many children under age 18 are living in your home?

What best describes your current employment status?

What is the zip code where you live?

Please add up your "YES" answer  to View you ACE Score

1. Did a parent or other adult in the household often or very 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?
2. Did a parent or other adult in the household often or very often push, grab, slap, or throw something at you? or, Ever hit you so hard that you had marked or were injured?
3. Did an adult or person at least 5 years older in a sexual way?
4.  Did you often or very 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?
5. Did you often or very 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?
6. Was a biological parent ever lost to you through divorce, abandonment, imprisonment, or other reason?
7. Was your mother or stepmother ofter or very often pushed, grabbed, slapped, or had something thrown at her? or, Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or, Ever repeatedly was hit over at least a few minutes or threatened with a gun or knife?
8. Did you live with anyone who was a problem drinking 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?