KIDS ACE Questionnaire - Dr. Brian Alman
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KIDS ACE Questionnaire

Welcome to your KIDS ACE Questionnaire

1. Does 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?

2. Does 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?

3. Does 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?

4. Do 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?

5. Do 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?

6. Was a biological parent ever lost to you through divorce, abandonment, or other reason?

7. Is 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 over at least a few minutes or threatened with a gun or knife?

8. Do you live with anyone who is a problem drinker or alcoholic, or who used street drugs?

9. Is a household member depressed or mentally ill, or did a household member attempt suicide?

10. Did a household member ever go to prison?

11. Is there anything that has happened in your life that still bothers you? If so, please note it here.

12. Please go back and look at all of your "yes" responses and write down the impact and effects those things have had on your life. After taking the ACE, this one question has proven to be very helpful, important, and healing when people take the time to answer thoughtfully

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