Adverse Childhood Experience (ACE) Questionnaire Finding your ACE ScoreClient's Name* First Last Client's Date of Birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the Patient under 18 years old?* Yes No Parent/Guardian Name* First Last Email Enter Email Confirm Email 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 it? Yes No 6. Were your parents ever separated or divorced? Yes No 7. Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? Yes No 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 This is your ACE score:
