.
3. Did an adult or person at least five years older than you ever …
Touch or fondle you or 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 ___
4. Did you 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 ___
5. Did you 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 ___
6. Were your parents ever separated or divorced? Yes No If yes enter 1 ___
7. Was your mother or stepmother …
Often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or 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 a knife? Yes No If yes enter 1 ___ 8. Did you live with anyone who was a problem drinker or alcoholic or used street drugs? Yes No If yes enter 1 ___ 9. Was a household member depressed or mentally ill, or did a household member attempt suicide? Yes No If yes enter 1 ___
10. Did a household member go to prison?
Yes No
If yes enter 1 ___
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