Items:

Maltreatment ACEs
1. Have you ever been scared that your parents or other adults were going to hurt you badly (so that you were injured or killed)?
2. Have you ever been scared or felt really bad because grown-ups called you names, said mean things to you, or said they did not want you?
3. Has there ever been a time of your life when you were totally on your own and had to take care of yourself for more than a short time?
4. Have you ever felt like you are not loved or cared about?
5. Have you ever felt like you have no one that protects you?
6. Has an adult ever touched you in your private parts except when being bathed?
7. Has an adult ever attempted or forced you to have sexual intercourse?

Household ACEs
8. Have your parents/guardian ever drunk too much alcohol or used drugs so they came home and were really abusive to you or your family?
9. Have you ever seen your mother or father so sad that they could not take care of you?
10. Have you ever seen your mom being hit, beaten or threatened?
11. Have any of your parents ever been in prison/jail?

Response Options:
Often - 1
Sometimes - 1
Never - 0
Don't know
Refuse to answer