ACES – SoCalEM

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Adverse Childhood Experience Questionnaire for Adults

Our relationships and experiences—even those in childhood—can affect our health and well-being. Difficult childhood experiences are very common. Please tell us whether you have had any of the experiences listed below, as they may be affecting your health today or may affect your health in the future. This information will help you and your provider better understand how to work together to support your health and well-being.

Patient First and Last Name *

Patient DOB *

Would you like a copy of this completed form emailed to you? *

Email *

Instructions

Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please select Yes to each ACE category that you experienced prior to your 18th birthday. Then, please add up the number of categories of ACEs you experienced and put the total number at the bottom.

1. Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?

1-Yes

2. Did you lose a parent through divorce, abandonment, death, or other reason?

1-Yes

3. Did you live with anyone who was depressed, mentally ill, or attempted suicide?

1-Yes

4. Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?

1-Yes

5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?

1-Yes

6. Did you live with anyone who went to jail or prison?

1-Yes

7. Did a parent or adult in your home ever swear at you, insult you, or put you down?

1-Yes

8. Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?

1-Yes

9. Did you feel that no one in your family loved you or thought you were special?

1-Yes

is family down?

10. Did you experience unwanted sexual contact (such as fondling or oral/anal/vaginal intercourse/penetration)?

1-Yes

Your ACE score is the total number of checked responses

Do you believe that these experiences have affected your health? *

Not Much
Some
A Lot

Patient/Guarantor Signature *

Clear Signature