Adverse Childhood ExperiencePrior to your 18th birthday:
Did a parent or other adult in the household often or very often… Swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
No___If Yes, enter 1 __
Did a parent or other adult in the household often or very often… Push, grab, slap, or throw something at you? or Ever hit you so hard that you had marks or were injured?
No___If Yes, enter 1 __
Did an adult or person at least 5 years older than you ever… Touch or fondle you or have you touch their body in a sexual way? or Attempt or actually have oral, anal, or vaginal intercourse with you?
No___If Yes, enter 1 __
Did you often or very often feel that … No one in your family loved you or thought you were important or special? or Your family didn’t look out for each other, feel close to each other, or support each other?
No___If Yes, enter 1 __
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? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
No___If Yes, enter 1 __
Were your parents ever separated or divorced?
No___If Yes, enter 1 __
Was your mother or stepmother:
Often or very often pushed, grabbed, slapped, or had something thrown at her? or Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
No___If Yes, enter 1 __
Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
No___If Yes, enter 1 __
Was a household member depressed or mentally ill, or did a household member attempt suicide?
No___If Yes, enter 1 __
Did a household member go to prison?
No___If Yes, enter 1 __
Now add up your “Yes” answers: _ This is your ACE Score[/size]
RESILIENCE Questionnaire1. I believe that my mother loved me when I was little.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True2. I believe that my father loved me when I was little.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True3. When I was little, other people helped my mother and father take care of me and they seemed to love me.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True4. I’ve heard that when I was an infant someone in my family enjoyed playing with me, and I enjoyed it, too.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True5. When I was a child, there were relatives in my family who made me feel better if I was sad or worried.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True6. When I was a child, neighbors or my friends’ parents seemed to like me.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True7. When I was a child, teachers, coaches, youth leaders or ministers were there to help me.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True8. Someone in my family cared about how I was doing in school.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True9. My family, neighbors and friends talked often about making our lives better.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True10. We had rules in our house and were expected to keep them.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True11. When I felt really bad, I could almost always find someone I trusted to talk to.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True12. As a youth, people noticed that I was capable and could get things done.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True13. I was independent and a go-getter.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not True14. I believed that life is what you make it.
Definitely true Probably true Not sure Probably Not True  :)efinitely Not TrueHow many of these 14 protective factors did I have as a child and youth? (How many of the 14 were circled “Definitely True” or “Probably True”?) _______
Of these circled, how many are still true for me? _______
www.acestoohigh.com/got-your-ace-score/
See list of all self-assessment surveys