Name
*
First Name
Last Name
Adverse Childhood Experience (ACE)
Finding your ACE Score
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 the made you afraid that you might get physically hurt?
*
Yes
No
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
3. Did an adult 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
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?
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Yes
No
5. Did you often feel that... You didn't have enough to eat, had to wear dirty cloths, 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?
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Yes
No
6. Were your parents ever separated or divorced?
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Yes
No
7. Was you mother or stepmother: Often pushed, grabbed, slapped, or had something thrown at her? or Sometime 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?
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Yes
No
8. Did you live with anyone who was a problem drinker or alcoholic or used street drugs?
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Yes
No
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
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Yes
No
10. Did a household member go to prison?
*
Yes
No
Now ADD up your "Yes" answers and enter the number below:
*
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Mood Disorder Questionnaire (MDQ)
Please answer each question as best as you can.
1. Has there ever been a period of time where you were not you usual self and......
... you felt so good or hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
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Yes
No
... you were so irritable that you shouted at people or started fights or arguments?
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Yes
No
... you felt much more self-confident than usual?
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Yes
No
... you got much less sleep than usual and found you didn't really miss it?
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Yes
No
... you were much more talkative or spoke faster than usual?
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Yes
No
... thoughts raced though your head or you couldn't slow your mind down?
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Yes
No
... you were easily distracted by things around you that you had trouble concentrating or staying on track?
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Yes
No
... you had much more energy than usual?
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Yes
No
... you were much more active or did many more things than usual?
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Yes
No
... you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night?
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Yes
No
... you were much more interested in sex than usual?
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Yes
No
... you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky?
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Yes
No
... spending money got you or your family in trouble?
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Yes
No
2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? (Please check 1 response only)
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Yes
No
3. How much of a problem did any of these cause you - like being able to work; having family, money, or legal troubles; getting into arguments or fights?
No Problem
Minor Problem
Moderate Problem
Serious Problem
(Select One Only)
4. Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder?
*
Yes
No
5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder?
*
Yes
No
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Subjective Opiate Withdrawal Scale (SOWS)
*
Not at All (0)
A little (1)
Moderately (2)
Quite a Bit (3)
Extremely (4)
I feel anxious
I feel like yawning
I am perspiring
My eyes are tearing
My nose is running
I have goosebumps
I am shaking
I have hot flushes
I have cold flushes
My bones and muscles ache
I fell restless
I feel nauseous
I feel like vomiting
My muscles twitch
I have stomach cramps
I feel like using now
Now ADD up your answers and enter the total number below:
*
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Personal Drug Use Questionnaire (SOCRATES)
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NO! Strongly Disagree (1)
No Disagree (2)
? Undecided or Unsure (3)
Yes Agree (4)
YES! Strongly Agree (5)
I really want to make changes in my use of drugs.
Sometimes I wonder if I am an addict.
If I don't change my drug use soon, my problems are going to get worse.
I have already started making some changes in my use of drugs.
I was doing drugs too much at one time, but I've managed to change that.
Sometimes I wonder if my drug use is hurting other people.
I have a drug problem.
I'm not just thinking about changing my drug use, I'm already doing something about it.
I have already changed my drug use, and I am looking for ways to keep from slipping back to my old pattern.
I have serious problems with drugs.
Sometimes I wonder if I am in control of my drug use.
My drug use is causing a lot of harm.
I am actively doing things now to cut down or stop my use of drugs.
I want help to keep from going back to the drug problems that i had before.
I know i have a drug problem.
There are times when I wonder if I use drugs too much.
I am an addict
I am working hard to change my drug use.
I have made some changes in my drug use, and I want some help to keep from going back to the way I used before.
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LEC-5 Standard Listed below are a number of difficult or stressful things that sometimes happen to people. Be sure to consider your entire life (growing up as well as adulthood) as you go through the list of events.
*
Happened to me
Witnessed it
Learned about it
Part of my job
Not sure
Doesn't apply
Natural disaster (flood, earthquake, hurricane, tornado, etc.)
Fire or Explosion
Transportation accident (car, boat, train, plane, etc.)
Serious accident at work, home, or during recreational activity
Exposure to toxic substance (dangerous chemicals, radiation, etc.)
Physical assault (bring attacked, hit, slapped, kicked, beaten up, etc.)
Assault with a weapon (being shot, stabbed, threatened with a knife, gun, bomb, etc.)
Sexual assault ( rape, attempted rape, made to perform any type of sexual act through force or threat of harm)
Other unwanted or uncomfortable sexual experience
Combat or exposure to war-zone (in the military or as a civilian)
Captivity (bring kidnapped, abducted, held hostage, prisoner of war, etc.)
Life-threatening illness or injury
Severe human suffering
Sudden violent death (homicide, suicide, etc.)
Sudden accidental death
Serious injury, harm, or death you caused to someone else
Any other very stressful event or experience
Submit
Should be Empty: