This is a much-shortened version of the ACE Study questionnaire that 17,337 adults filled out at Kaiser Permanente in San Diego. The original questionnaire, which is on the CDC ACE Study site has more than 200 questions.

Prior to your 18th birthday:

1. 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, give yourself one point.

2. 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, give yourself one point.

3. 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, give yourself one point.

4. 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, give yourself one point.

5. 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, give yourself one point.

6. Was a biological parent ever lost to you through divorce, abandonment, or other reason ?

Yes/No.

If yes, give yourself one point.

7. Was your mother or stepmother:

Often or very often pushed, grabbed, slapped, or had 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, give yourself one point.

8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

Yes/No.

If yes, give yourself one point.

9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

Yes/No.

If yes, give yourself one point.

10. Did a household member go to prison?

Yes/No.

If yes, give yourself one point.

Now add up your “Yes” answers: _______ This is your ACE Score