Appendix 1

WHAT’S MY ACE SCORE?

Prior to your eighteenth birthday:

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 you might be physically hurt?
	Yes     No	If yes enter 1 _____
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?
	Yes     No	If yes enter 1 _____
3.	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?
	Yes     No	If yes enter 1 _____
4.	Did you 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?
	Yes     No	If yes enter 1 _____
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?
	Yes     No	If yes enter 1 _____
6.	Were your parents ever separated or divorced?
	Yes     No	If yes enter 1 _____
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?
	Yes     No	If yes enter 1 _____
8.	Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
	Yes     No	If yes enter 1 _____
9.	Was a household member depressed or mentally ill, or did a household member attempt suicide?
	Yes     No	If yes enter 1 _____
10.	Did a household member go to prison?
	Yes     No	If yes enter 1 _____

Now add up your “Yes” answers.

This is your ACE Score.