Survey contains language that is not suitable

for children.  Our parents complete the survey

for our children.


Adverse Childhood Experience (ACE)

Study Questionnaire

1. Did a parent or other adult in the household often …

    Swear at you, insult you, put you down, or humiliate you?    


    Act in a way that made you afraid that you might be physically hurt?  

      YES    NO


2. Did a parent or other adult in the household often ...

    Push, grab, slap, or throw something at you?


    Ever hit you so hard that you had marks or were injured?    

     YES     NO


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?   


    Try to or actually have sex with you?

       YES         NO

4. Did you often feel that …

    No one in your family loved you or thought you were important or special?


    Your family didn’t look out for each other, feel close to each other, or support each other?

      YES       NO

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?


    Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

      YES     NO


6. Were your parents ever separated or divorced?   YES    NO


7. Was your mother or stepmother:

    Often pushed, grabbed, slapped, or had something thrown at her?


    Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?


    Ever repeatedly hit over at least a few minutes or threatened with a gun or knife? YES NO


8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?          YES    NO


9. Was a household member depressed or mentally ill or did a household member attempt  suicide?    YES   NO


10. Did a household member go to prison?  YES   NO


Now add up your “Yes” answers:________

This is your ACE Score________/10


ACE stands for Adverse Childhood Experience. Many people have experienced multiple ACEs in their lifetime.  With a stable, caring adult and skills of resilience, ACEs can be overcome to a large extent.  However, without a stable, caring adult or learning skills associated with resilience, ACEs can carry devastating long-term health consequences.  The charts to the right and below from the Center for Disease Control illustrate the lasting effects of untreated Adverse Childhood Experiences.