Adverse Childhood Experience Questionnaire

Date

swear at you, insult you, put you down, or humiliate you?

Act in a way that made you afraid that you might be physically hurt?

None

Push, grab, slap, or throw something at you?

Ever hit you so hard that you had marks or were injured?

None

Touch or fondle you or have you touch their body in a sexual way?

Try to or actually have oral, anal, or vaginal sex with you?

None

No one in your family loved you or thought you were important or special?

Your family didn’t look out for each other, feel close to each other, or support each other?

None

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

None

Yes

Often pushed, grabbed, slapped, or had something thrown at her?

Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?

Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

None

Yes

Yes

Yes