ACE score

Adverse Childhood Experience (ACE) Questionnaire

Finding your ACE Score

While you were growing up, during your first 18 years of life:

1. 

Did a parent or other adult in the household 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?

2. 

Did a parent or other adult in the household often:
Push, grab, slap, or throw something at you? or
Ever hit you so hard that you had marks or were injured?

3. 

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

4. 

Did you often feel: 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?

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?

6. 

Were your parents ever separated or divorced?

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 knife?

8. 

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

9. 

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

10. 

Did a household member go to prison?

PTSD Checklist

PTSD Checklist (PCL-5)

Instructions: Below is a list of problems that people sometimes have in response to a very stressful experience. Please read each problem carefully and then circle one of the numbers to the right to indicate how much you have been bothered by that problem in the past month.

In the past month, how much were you bothered by:

1. 

Repeated, disturbing, and unwanted memories of the stressful experience?

2. 

Repeated, disturbing dreams of the stressful experience?

3. 

Suddenly feeling or acting as if the stressful experience were actually happening again (as if you were actually back there reliving it)?

4. 

Feeling very upset when something reminded you of the stressful experience?

5. 

Having strong physical reactions when something reminded you of the stressful experience (for example, heart pounding, trouble breathing, sweating)?

6. 

Avoiding memories, thoughts, or feelings related to the stressful experience?

7. 

Avoiding external reminders of the stressful experience (for example, people, places, conversations, activities, objects, or situations)?

8. 

Trouble remembering important parts of the stressful experience?

9. 

Having strong negative beliefs about yourself, other people, or the world (for example, having thoughts such as: I am bad, there is something seriously wrong with me, no one can be trusted, the world is completely dangerous)?

10. 

Blaming yourself or someone else for the stressful experience or what happened after it?

11. 

Having strong negative feelings such as fear, horror, anger, guilt, or shame?

12. 

Loss of interest in activities that you used to enjoy?

13. 

Feeling distant or cut off from other people?

14. 

Trouble experiencing positive feelings (for example, being unable to feel happiness or have loving feelings for people close to you)?

15. 

Irritable behavior, angry outbursts, or acting aggressively?

16. 

Taking too many risks or doing things that could cause you harm?

17. 

Being “superalert” or watchful or on guard?

18. 

Feeling jumpy or easily startled?

19. 

Having difficulty concentrating?

20. 

Trouble falling or staying asleep?