BRFSS Adverse Childhood Experience (ACE)
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Below are some questions about events that happened during your childhood (patient's childhood). This information will allow us to better understand problems that may occur early in life and may help others in the future. All questions refer to the time period before you were 18 years of age. A place for comment is also provided should you wish to offer additional information. Now, looking back before you were 18 years of age . . .
1) Did you live with anyone who was depressed, mentally ill, or suicidal? *

1 = Yes 2 = No 7 = Don't Know/Not Sure 9 = Refused
Comment Section

0/5000
2) Did you live with anyone who was a problem drinker or alcoholic? *

1 = Yes 2 = No 7 = Don't Know/Not Sure 9 = Refused
Comment Section

0/5000
3) Did you live with anyone who used illegal street drugs or who abused prescription medications? *

1 = Yes 2 = No 7 = Don't Know/Not Sure 9 = Refused
Comment Section

0/5000
4) Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? *

1 = Yes 2 = No 7 = Don't Know/Not Sure 9 = Refused
Comment Section

0/5000
5) Were your parents separated or divorced? *

1 = Yes 2 = No 7 = Don't Know/Not Sure 8 = Parents not married 9 = Refused
Comment Section

0/5000
6) How often did your parents or adults in your home ever slap, hit, kick, punch, or beat each other up? *

1 = Never 2 = Once 3 = More than once 7 = Don't know/Not sure 9 = Refused
Comment Section

0/5000
7) Not including spanking, (before age 18), how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? *

1 = Never 2 = Once 3 = More than once 7 = Don't know/Not sure 9 = Refused
Comment Section

0/5000
8) How often did a parent or adult in your home ever swear at you, insult you, or put you down? *

1 = Never 2 = Once 3 = More than once 7 = Don't know/Not sure 9 = Refused
Comment Section

0/5000
9) How often did anyone at least 5 years older than you or an adult, ever touch you sexually? *

1 = Never 2 = Once 3 = More than once 7 = Don't know/Not sure 9 = Refused
Comment Section
10) How often did anyone at least 5 years older than you or an adult, try to make you touch them sexually? *

1 = Never 2 = Once 3 = More than once 7 = Don't know/Not sure 9 = Refused
Comment Section

0/5000
11) How often did anyone at least 5 years older than you or an adult, force you to have sex? *

1 = Never 2 = Once 3 = More than once 7 = Don't know/Not sure 9 = Refused
Comment Section

0/5000
12) For how much of your childhood was there an adult in your household who made you feel safe and protected? Would you say never, a little of the time, some of the time, most of the time, or all of the time? *

1 = Never 2 = A little of the time 3 = Some of the time 4 = Most of the time 5 = All of the time 7 = Don't know/Not sure 9 = Refused
Comment Section

0/5000
13) For how much of your childhood was there an adult in your household who tried hard to make sure your basic needs were met? Would you say never, a little of the time, some of the time, most of the time, or all of the time? *

1 = Never 2 = A little of the time 3 = Some of the time 4 = Most of the time 5 = All of the time 7 = Don't know/Not sure 9 = Refused
Comment Section

0/5000
Should be Empty: