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ACES Evaluation form

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Your ACEs score sheds light on how childhood experiences shape lifelong health. Understanding it is the first step toward healing, resilience, and building a brighter, more informed future. Empower yourself today.

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    Socio-demographic Profile



    FemaleMaleOther




    High SchoolCollegeOther


    While you were growing up, during your first 18 years of life:

    1. Did a parent or another adult in your home swear at you, insult you, humiliate you, or put you down?

    YesNo

    2. Did a parent or other adult in your home push, grab, slap, hit, beat, kick or physically hurt you or leave marks on your body?

    YesNo

    3. Did an adult or person at least 5 years older than you sexually touch you or try to make you sexually touch their body, or attempt to have sex with you?

    YesNo

    4. Did you feel that no one in your family loved you or thought of you as an important family member? Did they not look out for you, nor look out for each other or support each other?

    YesNo

    5. Did you feel that you didn't have enough food, wore dirty clothes and/or had no one to protect you? Were your parents too drunk or high to take care of you or take you to the doctor when needed?

    YesNo

    6. Were your parents separated or divorced?

    YesNo

    7. Was your mother or stepmother treated with violence? Or did your parents or another adult in the home slap, hit, kick, punch or beat each other?

    YesNo

    8. Had a household member a problem with drinking alcohol, used street drugs, and/or abused prescription medications?

    YesNo

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

    YesNo

    10. Did a household member go to prison?

    YesNo

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