ACE 10-Question Survey

PRIOR TO YOUR 18th BIRTHDAY:  Did a parent or other adult in the household often or very often….
Swear at you, insult you, put you down, or humiliate you?    OR Act in a way that made you afraid that you might be physically hurt? 
Yes     No    If yes enter 1   _____   

Did a parent or other adult in the household often or very often…..
Push, grab, slap, or throw something at you? OR Ever hit you so hard that you had marks or were injured? 
Yes     No    If yes enter 1   _____   

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?  OR Attempt or actually have oral, anal, or vaginal intercourse with you? 
Yes     No    If yes enter 1   _____   

Did you often or very 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? 
Yes     No    If yes enter 1   _____   

Did you often or very often feel that..... 
You didn’t have enough to eat, had to wear dirty clothes, 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? 
Yes     No    If yes enter 1   _____   

Was a biological parent ever lost to you through divorce, abandonment, or other reason? 
Yes     No    If yes enter 1   _____   

Was your mother or stepmother: 
Often or very often pushed, grabbed, slapped, or ad something thrown at her?  OR  Sometimes, often, or very 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? 
Yes     No    If yes enter 1   _____   

Did you live with anyone who was a problem drinker or alcoholic or who used street  drugs?   
Yes     No    If yes enter 1   _____   
Was a household member depressed or mentally ill or did a household member attempt  suicide?   
Yes     No    If yes enter 1   _____   

Did a household member go to prison?
Yes     No    If yes enter 1   _____   

Now add up your YES answers:  _______    This is your ACE score.

​NOTE:  Sometimes people take exception to the phrasing of questions 3, 6, and 7, arguing that sexual assault by anyone of any age is traumatic, that the death of a parent should be included, and that both males and females can be victims of domestic violence.  If, when taking the survey, you prefer to modify the questions to allow for these factors, you may feel free to do so.