Adverse Childhood Experiences Questionnaire (ACE-Q)

Child's Name*

Today's Date*

Your Name*

Relationship to Child*

Many children experience stressful life events that can affect their health and wellbeing. The results from this questionnaire will assist your child’s doctor in assessing their health and determining guidance. Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided.

Please DO NOT mark or indicate which specific statements apply to your child.

1) Of the statements in Section 1, HOW MANY apply to your child? Write the total number in the box.*

Section 1. At any point since your child was born until today…

▪ Your child’s parents or guardians were separated or divorced
▪ Your child lived with a household member who served time in jail or prison
▪ Your child lived with a household member who was depressed, mentally ill or attempted suicide
▪ Your child saw or heard household members hurt or threaten to hurt each other
▪ A household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurt
▪ Someone touched your child’s private parts or asked your child to touch their private parts in a sexual way
▪ More than once, your child went without food, clothing, a place to live, or had no one to protect her/him
▪ Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marks
▪ Your child lived with someone who had a problem with drinking or using drugs
▪ Your child often felt unsupported, unloved and/or unprotected

2) Of the statements in Section 2, HOW MANY apply to your child? Write the total number in the box.*

Sección 2. Desde que nació hasta hoy …

▪ Su hijo ha experimentado o ha sido testigo de alguna violencia mientras viajaba a los Estados Unidos
▪ Ha vivido su hijo con un padre, tutor o familiar cercano que murió
▪ Su hijo ha tenido miedo de que los miembros de la familia sean deportados o fue separado de cualquier miembro de la familia debido a deportación
▪ Su hijo, o algún miembro de la familia, ha tenido alguna afección médica potencialmente mortal
▪ Su hijo ha sido intimidado o testigo de violencia en el vecindario o en su escuela, actual
vecindario o en su país de origen
▪ Su hijo ha sido maltratado debido a su raza, orientación sexual, lugar de nacimiento, discapacidad, religión o estado migratorio