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    ACE Score Questionnaire

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    Eva Dvorakova
    The document is a questionnaire that measures an individual's Adverse Childhood Experiences (ACE) Score based on 10 categories of traumatic experiences that occurred before the age of 18. The ACE Score is calculated by adding up the number of "yes" answers and represents the total number of these adverse experiences an individual endured as a child or adolescent.

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    ACE Score Questionnaire

    Uploaded by

    Eva Dvorakova
    272 views1 page
    The document is a questionnaire that measures an individual's Adverse Childhood Experiences (ACE) Score based on 10 categories of traumatic experiences that occurred before the age of 18. The ACE Score is calculated by adding up the number of "yes" answers and represents the total number of these adverse experiences an individual endured as a child or adolescent.

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    ACE_score_questionnaire

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    The document is a questionnaire that measures an individual's Adverse Childhood Experiences (ACE) Score based on 10 categories of traumatic experiences that occurred before the age of 18. The ACE Score is calculated by adding up the number of "yes" answers and represents the total number of these adverse experiences an individual endured as a child or adolescent.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    272 views1 page

    ACE Score Questionnaire

    Uploaded by

    Eva Dvorakova
    The document is a questionnaire that measures an individual's Adverse Childhood Experiences (ACE) Score based on 10 categories of traumatic experiences that occurred before the age of 18. The ACE Score is calculated by adding up the number of "yes" answers and represents the total number of these adverse experiences an individual endured as a child or adolescent.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    What’s My ACE Score?

    Prior to your 18th birthday:


    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 If yes enter 1 ________

    2. Did a parent or other adult in the household often or very 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
    Attempt or actually have oral, anal, or vaginal intercourse with you?
    Yes No If yes enter 1 ________

    4. 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 If yes enter 1 ________

    5. 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 If yes enter 1 ________

    6. Was a biological parent ever lost to you through divorce, abandonment, or other reason ?
    Yes No If yes enter 1 ________

    7. 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 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 ________

    9. Was a household member depressed or mentally ill or did a household member attempt suicide?
    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

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