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Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs) encompass a spectrum of traumatic events, from abuse and neglect to household dysfunction, which profoundly impact a person's development and well-being. These experiences can leave lasting imprints on individuals, influencing their physical health, mental health, and social functioning well into adulthood. By understanding ACEs and their effects, we can begin to address the root causes of adversity, promote healing, and foster resilience in individuals and communities. Through compassionate support and trauma-informed care, we can create environments that nurture growth, recovery, and thriving beyond past hardships.

Adverse Childhood Experience's 

Our connections and life encounters, even those from childhood, can significantly impact our health and overall well-being. It's common to have faced challenging experiences during childhood. Please indicate if you've encountered any of the situations listed below prior to turning 18, as they might currently affect your health or pose future implications. This information will aid both you and your healthcare provider in better comprehending how to collaborate towards supporting your health and well-being.

Instructions: Below, you'll find a list of 10 categories of Adverse Childhood Experiences (ACEs). Please mark each ACE category you experienced before reaching the age of 18 with a checkmark. Then, tally up the number of ACE categories you've experienced and record the total at the bottom.

Question 1
Emotional Abuse

Did a parent or other adult in the household often or very often, swear at you, insult you, put you down and/or threaten you in a way that made you think that you might be physically hurt?

Question 2
Physical Abuse

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?

Question 3
Sexual Abuse 

Did an adult or person ever touch or fondle or have you touch their body in a sexual way?
Did anyone attempt or actually have oral, anal, or vaginal intercourse with you?

Question 4
Emotional Neglect

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?

Question 5
Physical Neglect

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?

Question 6
Family Violence

Did a parent or guardian often, or very often pushed, grabbed, slapped; or had something thrown at them? Sometimes, often, or very often kicked, bitten, hit with a fist or something hard? Ever threatened or hurt by a knife or gun or other weapon?

Question 7
Household Substance Abuse

As a child, did you ever live with anyone who was a problem drinker or alcoholic or lived with anyone who used street drugs?

Question 8
Household Mental Illness

Was a household member ever depressed; mentally ill or sent to a mental hospital? Has a family member ever attempted suicide?

Question 9
Parental Divorce

As a child, were your parents ever separated (didn’t live together) or divorced?

Question 10
Household Incarceration

Did a household member ever go to prison, or was constantly in and out of jail?

About You!

Name ________________________________________________________________________________________________________________

Age __________________________________________________________________________________________________________________

Profession ___________________________________________________________________________________________________________

Are you currently seeing a therapist ___________________________________________________________________________________

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