Adverse Child Experiences (ACEs) Screening Tool The ACE questionnaire for adults is adapted from the work of Kaiser Permanente and the Centers for Disease Control and Prevention. The adult screening tool was compiled by the Office of the California Surgeon General and Department of Health Care Services in consultation with the California Surgeon General’s Clinical Advisory Subcommittee. For more information, visit Screening Tools | ACEs Aware – Take action. Save lives.Member InformationFirst Name(Required) Last Name(Required) Date of Birth(Required) Preferred Email Address(Required) Finding Your ACE Score The ACE questionnaire is a simple scoring system that attributes one point for each category of adverse childhood experience. The 10 questions below each cover a different domain of trauma, and refer to experiences that occurred prior to the age of 18. Higher scores indicate increased exposure to trauma, which have been associated with a greater risk of negative consequences.If the answer to any of the following questions is yes, check the box next to the question. While you were growing up, during your first 18 years of life:(Required) 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? 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? Did an adult or person at least five 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? 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? 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? Were your parents ever separated or divorced? 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 at least a few minutes or threatened with a gun or knife? Did you live with anyone who was a problem drinker or alcoholic or who used street drugs? Was a household member depressed or mentally ill, or did a household member attempt suicide? Did a household member go to prison? Now add up your "checkmarks" and enter the numerical total in the box below. This is your ACE Score.Do you believe that these experiences have affected your health?(Required) Not Much Some A Lot Confidentiality Notice Acknowledgement The information provided in this form contains protected health information (PHI) protected by federal and state privacy laws. Your PHI will be kept confidential and used solely for authorized purposes. We will share your PHI electronically and use encryption and access controls to safeguard your PHI during transmission and storage. By submitting this form, you acknowledge the collection and use of your PHI as outlined in the Notice of Privacy Policy.I consent to the above Confidentiality Notice(Required) Yes No
