.
Now add up your “Yes” answers: ____
This is your ACE Score.
CYW ADVERSE CHILDHOOD EXPERIENCES QUESTIONNAIRE (ACE-Q) CHILD (Permission to reprint as part of Guided Activity Workbook in progress )
To Be Completed by Parent/Caregiver
Today’s Date: ___________________________
Child’s Name: ___________________________ Date of Bir th: _________________________
Your Name: _____________________________ Relationship to Child: ___________________
Many children experience stressful life events that can affect their health and well-being. The results from this questionnaire will assis t your child’s doctor in assessing his or her health and determining guidance.
Please read the statements below. Count the number of statements that apply to your child and write the total number in the box provided.
Please DO NOT mark or indicate which specific statements apply to your child.
1) Of the following statements in Section 1, HOW MANY apply to your child?
Write the number in the box
Section 1. At any point since your child was born …
• Your child’s pa rents or guardians were divorced. • Your child lived with a household member who served time in jail or prison. • Your child lived with a household member who was depressed, mentally ill, or attempted suicide. • Your child saw or heard household members hurt or threaten to hurt each other. • A household member swore at, insulted, humiliated, or put down your child in a way that scared your child, OR a household member acted in a way that made your child afraid that she or he might be physically hurt. • Someone touche d your child’s private parts or asked your child to touch their private parts in a sexual way. • More than once, your child went without food, clothing, or a place to live, or had no one to protect her or him. • Someone pushed, grabbed, slapped, or threw something at your child, OR your child was hit so hard that your child was injured or had marks.
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