Questionnaire for Assessing Adverse Childhood Experiences, ACE-10 Test - the question form
Questions: 10 · 2 minutes
1. Did a parent or other adult in the household often or very often swear at you, insult you, or put you down? Or act in a way that made you afraid you might be physically hurt?
Yes
No
2. Did a parent or other adult in your 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
3. Did an adult, or a 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
4. Did you often or very often feel that no one in your family loved you or thought you were important? Or that your family members did not look out for each other, feel close to each other, or support each other?
Yes
No
5. Did you often or very often feel that you did not have enough to eat, had to wear dirty clothes, and that no one took care of you? Or that your parents were too intoxicated by alcohol or drugs to take care of you or take you to a doctor when you needed help?
Yes
No
6. Did your parents divorce or separate?
Yes
No
7. Did anyone do any of the following to your mother or stepmother: often or very often push, grab, slap, or throw something at her; or sometimes, often, or very often kick, bite, or hit her with a fist or something hard; or ever repeatedly hit her for at least a few minutes or threaten her with a knife or firearm?
Yes
No
8. Did you live with anyone who was a problem drinker or who used street drugs?
Yes
No
9. Did you live with anyone who was depressed or had a mental illness, or who attempted suicide?
Yes
No
10. Did someone you lived with go to prison?
Yes
No