ACE Health Questionnaire

CYW Adverse Childhood Experiences Questionnaire (ACE-Q) Teen Self-Report

To be completed by Patient

Today's Date*

Your Name*

First NameLast Name

Date of Birth*

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

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

1) Of the statements in section 1, HOW MANY apply to you? Enter the total number in the box.*

Section 1. At any point since you were born...

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

2) Of the statements in section 2, HOW MANY apply to you? Enter the total number in the box*

Section 2. At any point since you were born...

You have been in foster care
You have experienced harassment or bullying at school
You have lived with a parent or guardian who died
You have been separated from your primary caregiver through deportation or immigration
You have had a serious medical procedure or life threatening illness
You have often seen or heard violence in the neighborhood or in your school neighborhood
You have been detained, arrested or incarcerated
You have often been treated badly because of race, sexual orientation, place of birth, disability or religion
You have experienced verbal or physical abuse or threats from a romantic partner (i.e. boyfriend or girlfriend)