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* 1. Prior to your 18th birthday:

Did a household member 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?

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* 2. Prior to your 18th birthday:

Did a household member 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?

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* 3. Prior to your 18th birthday:

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, expose you to sexual images, convince you to share naked photos of yourself or threaten to expose naked photos of you to other people?

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* 4. Prior to your 18th birthday:

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?

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* 5. Prior to your 18th birthday:

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/carers were too overwhelmed, distracted, drunk or high to take care of you or take you to the doctor or hospital if you needed it?

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* 6. Prior to your 18th birthday:

Were your parents ever separated or divorced?

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* 7. Prior to your 18th birthday:

Was your mother or stepmother, father or step-father or other primary carer often or very often pushed, grabbed, slapped, or had something thrown at her/him, or sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard or ever repeatedly hurt or threatened with a gun or knife or object being used as a weapon?

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* 8. Prior to your 18th birthday:

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

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* 9. Prior to your 18th birthday:

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

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* 10. Prior to your 18th birthday:

Did a household member go to prison?

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