Section 1: ACE (Adverse Childhood Experiences) Questionnaire

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Instructions: Please answer “Yes” or “No” for each question about your childhood (before age 18).

Did a parent or other adult often swear at you, insult you, or put you down? *

Yes

Did a parent or other adult often push, grab, slap, or throw something at you? *

Yes

Did an adult or person at least 5 years older ever touch you sexually or try to make you touch them? *

Yes

Did you often feel that no one in your family loved you or thought you were important or special? *

Yes

Did you often feel you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect you? *

Yes

Were your parents ever separated or divorced? *

Yes

Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? *

Yes

Did you live with anyone who was a problem drinker, alcoholic, or who used street drugs? *

Yes

Was a household member depressed, mentally ill, or did they attempt suicide? *

Yes

Did a household member go to prison? *

Yes

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