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From the list below, please place a checkmark next to each ACE category that you experienced prior to your 18th birthday.
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Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?
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Did you lose a parent through divorce, abandonment, death, or other reason?
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Did you live with anyone who was depressed, mentally ill, or attempted suicide?
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Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?
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Did you live with anyone who went to jail or prison?
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Did a parent or adult in your home ever swear at you, insult you, or put you down?
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Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?
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Did you feel that no one in your family loved you or thought you were special?
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Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?
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ACE score is the total number of checked responses:
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Do you believe that these experiences have affected your health?
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