What’s My ACE Score?

Prior to your 18th birthday:

1. 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?
Yes No If yes enter 1 ________

2. 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?
Yes No If yes enter 1 ________

3. 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?
Yes No If yes enter 1 ________

4. 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?
Yes No If yes enter 1 ________

5. 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?
Yes No If yes enter 1 ________

6. Was a biological parent ever lost to you through divorced, abandonment, or other reason ?
Yes No If yes enter 1 ________

7. 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?
Yes No If yes enter 1 ________

8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?
Yes No If yes enter 1 ________

9. Was a household member depressed or mentally ill or did a household member attempt suicide?
Yes No If yes enter 1 ________

10. Did a household member go to prison?

Yes No If yes enter 1 ________

Now add up your “Yes” answers: _______ This is your ACE Score
 Trauma Screen and PTSD-DSM5 Checklist-Adult

Name: Date:

Stressful or scary events happen to many people. Below is a list of stressful and scary events
that sometimes happen. Mark YES if it happened to you. Mark No if it didn’t happen to you.

1. Serious natural disaster like a flood, tornado, hurricane,  Yes  No

earthquake, or fire.
2. Serious accident or injury like a car/bike crash, dog bite,  Yes  No
sports injury.
3. Robbed by threat, force or weapon.  Yes  No

4. Slapped, punched, or beat up in your family.  Yes  No

5. Slapped, punched, or beat up by someone not in your  Yes  No

family.
6. Seeing someone in your family get slapped, punched or  Yes  No
beat up.
7. Seeing someone in the community get slapped, punched  Yes  No
or beat up.
8. Someone older touching your private parts when they  Yes  No
shouldn’t.
9. Someone forcing or pressuring sex, or when you couldn’t  Yes  No
say no.
10. Someone close to you dying suddenly or violently.  Yes  No

11. Attacked, stabbed, shot at or hurt badly.  Yes  No

12. Seeing someone attacked, stabbed, shot at, hurt badly or  Yes  No
killed.
13. Stressful or scary medical procedure.  Yes  No

14. Being around war.  Yes  No

15. Other stressful or scary event?  Yes  No

Describe:

Which one is bothering you the most now?

If you marked “YES” to any stressful or scary events, then turn the page and
answer the next questions.
 Mark 0, 1, 2 or 3 for how often the following things have bothered you in the last two
weeks:

0 Never / 1 Once in a while / 2 Half the time / 3 Almost always

1. Upsetting memories about a stressful event that pop into your head unplanned or 0 1 2 3
when you are reminded.

2. Bad dreams related to a stressful event that feels like it is happening in the dream.
0 1 2 3
3. Acting or feeling as if the stressful event is happening right now.
0 1 2 3
4. Feeling very emotionally upset when you are reminded of a stressful event.
0 1 2 3
5. Strong physical reactions when reminded of a stressful event 0 1 2 3
(sweating, heart beating fast).
6. Trying not to remember, talk about or have feelings about a stressful event.
0 1 2 3
7. Avoiding activities, people, places or things that remind you of a stressful event.
0 1 2 3
8. Not being able to remember an important part of a stressful event.
0 1 2 3
9. Negative changes in how you think about yourself, others or the world after a 0 1 2 3
stressful event.
10. Thinking a stressful event happened because you or someone else did
0 1 2 3
something wrong or did not do enough to stop it.
11. Having a very negative emotional state (afraid, angry, guilty, ashamed).
0 1 2 3
12. Losing interest in activities you used to enjoy before a stressful event.
0 1 2 3
13. Feeling distant or cut off from people around you.
0 1 2 3
14. Not being able to have positive feelings (being happy, having loving feelings).
0 1 2 3
15. Feeling irritable or having angry outbursts without a good reason and taking it out
0 1 2 3
on other people or things.
16. Risky behavior or behavior that could hurt you.
0 1 2 3
17. Being overly alert or on guard.
0 1 2 3
18. Being jumpy or easily startled.
0 1 2 3
19. Problems with concentration.
0 1 2 3
20. Trouble falling or staying asleep.
0 1 2 3

Total _____
Please mark “YES” or “NO” if the problems you marked interfered with: Clinical = 21+

1. Getting along with others  Yes  No 4. Family relationships  Yes  No

2. Hobbies/Fun  Yes  No 5. General happiness  Yes  No

3. School or work  Yes  No

 PATIENT HEALTH QUESTIONNAIRE-9
(PHQ-9)
Over the last 2 weeks, how often have you been bothered More Nearly
by any of the following problems? Several than half every
(Use “✔” to indicate your answer) Not at all days the days day

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3

4. Feeling tired or having little energy 0 1 2 3

5. Poor appetite or overeating 0 1 2 3

6. Feeling bad about yourself — or that you are a failure or

0 1 2 3
have let yourself or your family down

7. Trouble concentrating on things, such as reading the

0 1 2 3
newspaper or watching television

8. Moving or speaking so slowly that other people could have

noticed? Or the opposite — being so fidgety or restless 0 1 2 3
that you have been moving around a lot more than usual

9. Thoughts that you would be better off dead or of hurting

0 1 2 3
yourself in some way

FOR OFFICE CODING 0 + ______ + ______ + ______

=Total Score: ______

If you checked off any problems, how difficult have these problems made it for you to do your
work, take care of things at home, or get along with other people?

Not difficult Somewhat Very Extremely

at all difficult difficult difficult

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from
Pfizer Inc. No permission required to reproduce, translate, display or distribute.
 GAD-7

More than
Over the last 2 weeks, how often have you Not Several Nearly
half the
been bothered by the following problems? at all days every day
days
(Use “✔” to indicate your answer)

1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being so restless that it is hard to sit still 0 1 2 3

6. Becoming easily annoyed or irritable 0 1 2 3

7. Feeling afraid as if something awful 0 1 2 3

might happen

(For office coding: Total Score T____ = ____ + ____ + ____ )

Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an
educational grant from Pfizer Inc. No permission required to reproduce, translate, display or distribute.