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Adverse Childhood Experiences Questionnaire

To help your counselor better understand your experiences, all patients are asked to complete the Adverse Childhood Experiences (ACE) questionnaire.

Birthday
Month
Day
Year

What does your ACE score mean?

As your ACE score increases, so does the risk of disease, social, and emotional problems. You may want to think about it as a way of measuring the amount of toxic stress you endured as a child and a way of alerting yourself to some statistical indicators of health risks.

The higher your ACE score the higher your chance of suffering from a range of psychological and medical problems like chronic depression, cancer, or coronary heart disease.

However, there are still some serious consequences of a lower score. A quarter of Americans have an ACE score of only one and their chance of becoming an alcoholic doubled. An ACE score of two means four times the risk of alcoholism and an ACE score of 3 may explain your chronic depression.

Knowing what your ACE score means being able to understand your risks and being able to prevent the possible consequences.


An ACE score is a tally of different types of abuse, neglect, and other hallmarks of a rough childhood. According to the Adverse Childhood Experiences study, the rougher your childhood, the higher your score is likely to be and the higher your risk for later health problems.


Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs).  From the list below, please place a checkmark next to each ACE category that you experienced prior to your 18th birthday. Then, please add up the number of categories of ACEs you experienced and put the total number at the bottom.


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