LEARN YOUR ACEs SCORE
First Name
Last Name
Please respond to the following questions Yes or No
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?
*
Yes
No
2. 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?
*
Yes
No
3. 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?
*
Yes
No
4. Were your parents ever separated or divorced?
*
Yes
No
5. Was your mother or stepmother: Often 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 hit at least a few minutes or threatened with a gun or knife?
*
Yes
No
6. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
*
Yes
No
7. Was a household member depressed or mentally ill, or did a household member attempt Suicide?
*
Yes
No
8. Did a household member go to prison?
*
Yes
No