An ACEs score of >4 indicates a child at risk •! These questions are in English have been designed for adults (age 18 and older). Adverse Childhood Experience (ACE) Questionnaire. Was a household member depressed or mentally ill or did a household member attempt suicide? Your ACE score is the total number of checked responses. Download a printable version (external link) of the ACE questionnaire. ACEs can be totaled using a score card (see above) •! a parent who's an alcoholic (or addicted to other drugs) or diagnosed with a mental illness o! [1] Warning: These questions may cause distress. bullying •! witnessing a parent experience abuse o! h�b``a``�````��ʀ This Questionnaire will be asking you some questions about events that happened during your childhood; specifically the first 18 years of your life. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes… �����A �fr�b �f��F003)��f�a^��,���\�l���7��Y����F��J��vn0d2$3��@V&C����@�&� I+,{�0�)�|�F��P5)��@�0���� e��b��(>X��d� ��6g`�r���UY00ղCDy����l���0 ��/� endstream endobj 150 0 obj <. 149 0 obj <> endobj 173 0 obj <>/Filter/FlateDecode/ID[<8873980B551FCF47938D9815438418FA><5F2477E0B1ED4BA187D4EB627C06869F>]/Index[149 41]/Info 148 0 R/Length 119/Prev 171455/Root 150 0 R/Size 190/Type/XRef/W[1 3 1]>>stream Some sample questions: Did a parent or other adult in the household often push, grab, slap, or throw something at you? h�bbd```b``���| �AD2�� R/�N�,l`r XW9���\ �S�&D�H�7`3�$c�؄� 2��=D�^����8������R���H))�EhQ�?� U.d endstream endobj startxref 0 %%EOF 189 0 obj <>stream losing a parent to abandonment or divorce o! Adverse Childhood Experience Questionnaire for Adults ... Did you lose a parent through divorce, abandonment, death, or other reason? o! Did you live with anyone who was depressed, mentally ill, or attempted suicide? Name: __________________________________________ Date: _____________________. %PDF-1.6 %���� ACES questionnaire developed by the CDC and Check that you have a support person or helpline number available before beginning. Some questions ask directly about experiences of child abuse. The information you provide by answering these questions will allow us to better understand problems that may have occurred early in …