Adverse Childhood Experience (ACE)
Questionnaire
Finding your ACE Score
While you were growing up, during your first 18 years
of life:
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
If yes enter 1 ________
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
If yes enter 1 ________
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
If yes enter 1 ________
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
If yes enter 1 ________
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
If
yes enter 1 ________
6. Were your parents ever separated or divorced?
Yes No
If
yes enter 1 ________
or
Sometimes or often
kicked, bitten, hit with a fist, or hit with something hard?
or
Ever
repeatedly hit over at least a few minutes or threatened with a gun or knife?
Yes No
If
yes enter 1 ________
8. Did you live with anyone
who was a problem drinker or alcoholic or who used street drugs?
Yes No
If yes enter 1 ________
Yes No
If yes enter 1 ________
10. Did a household member go
to prison?
Yes No
If yes enter 1 ________
Now add up your “Yes” answers: _______ This is your ACE Score
ACE Questionnaire ra hbr 10 24 06