ACE Health Questionnaire

ACE Questionnaire

CYW Adverse Childhood Experiences Questionnaire (ACE-Q) Child

To be completed by Parent/Caregiver

Today's Date *

Child's Name *

First Name Last Name

Date of Birth *

Your Name *

First Name Last 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? Enter the total number in the box. *

Section 1. At any point since your child was born...

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 your child down 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, or a place to live, or had no one to protect her/him
Someone pushed, grabbed, slapped or thew 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? Enter the total number in the box *

Section 2. At any point since your child was born...

Your child was in foster care
Your child experienced harassment or bullying at school
Your child lived with a parent or guardian who died
Your child was separated from her/his primary caregiver through deportation or immigration
Your child had a serious medical procedure or life threatening illness
Your child often saw or heard violence in the neighborhood or in his/her school neighborhood
Your child was often treated badly because of race, sexual orientation, place of birth, disability or religion