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Adverse Childhood Events Assessment
1. Did a parent or other adult in the household often or very often swear at you, put you down, or humiliate you? Did they act in a way that made you afraid that you might be physically hurt?
Yes
No
2. Did a parent or other adult in the household often or very often hit, beat, or physically hurt you in any way?
Yes
No
3. Did someone at least 5 years older than you or an adult ever touch or fondle you or have you touch their body in a sexual way?
Yes
No
4. Did you often or very often feel that no one in your family loved you or thought you were important or special?
Yes
No
5. 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?
Yes
No
6. Did your parent or stepparent often or very often push, grab, throw something at you, or hit you hard?
Yes
No
7. Did a household member often or very often drink alcohol or use drugs so that it interfered with their family life?
Yes
No
8. Did a household member suffer from a mental illness or attempt suicide?
Yes
No
9. Was a household member ever arrested?
Yes
No
10.Was a household member ever in prison?
Yes
No
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