This short 10-question questionnaire asks about experiences that happened during childhood. Research has shown that childhood abuse or neglect—known as Adverse Childhood Experiences (ACEs)—can influence long-term health and well-being. And can also be healed with counter-ACE's. Please answer each question based on your experiences before the age of 18. Select Yes if the statement applies to your childhood, or No if it does not. We will calculate the results and email your score and its significance once the questionnaire is submitted.

This short 10-question questionnaire asks about experiences that may have happened during childhood. Research has shown that certain types of early adversity—known as Adverse Childhood Experiences (ACEs)—can influence long-term health and well-being. Please answer each question based on your experiences before the age of 18. Select Yes if the statement applies to your childhood, or No if it does not. We will calculate the results and email your score and its significance once the questionnaire is submitted.

Did a parent or other adult in the household often or very often (a) Swear at you, insult you, put you down, or humiliate you? OR (b) Act in a way that made you afraid that you might be physically hurt? *

Yes

Did a parent or other adult in the household often or very often (a) Push, grab, slap, or throw something at you? OR (b) Ever hit you so hard that you had marks or were injured? *

Yes

Did a parent or other person at least 5 years older than you ever (a) Touch or fondle you or have you touch their body in a sexual way? OR (b) Attempt or actually have oral, anal, or vaginal intercourse with you? *

Yes

Did you often or very often feel that (a) No one in your family loved you or thought you were important or special? OR (b) Your family didn't look out for each other, feel close to each other, or support each other? *

Yes

Did you often or very often feel that (a) You didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? OR (b) Your parents were too drunk or high to take care of you or take you to the doctor if you needed it? *

Yes

Were your parents ever separated or divorced? *

Yes

Was your parent/caregiver (a) Often or very often pushed, grabbed, slapped or had something thrown at him/her? OR (b) Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? OR (c) Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? *

Yes

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

Yes

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

Yes

Did a household member go to prison? *

Yes

First Name *

Last Name *

Email *

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