Table 1 Questions asked about adverse childhood experiences
The following questions are about events that happened during YOUR childhood; that is, before 18 years of age. | Response options |
|---|---|
1. Did you live with anyone who was depressed, mentally ill, or suicidal? | Yes/no |
2. Did you live with anyone who was a problem drinker or alcoholic? | Yes/no |
3. Did you live with anyone who used illegal street drugs or who abused prescription medications? | Yes/no |
4. Did you live with anyone who served time or was sentenced to serve time in prison, jail or other correctional facility? | Yes/no |
5. Were your parents separated or divorced? | Yes/no |
6. How often did your parents or adults in your household ever slap, hit, kick, punch or beat each other up? | Yes/no |
7. Before age 18, how often did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? (Please do not include spanking) | Never/once/ more than once |
8. How often did a parent or adult in your home ever swear at you, insult you, or put you down? | Never/once/ more than once |
9. How often did anyone at least 5 years older than you or an adult ever touch you sexually? | Never/once/ more than once |
10. How often did anyone at least 5 years older than you or an adult try to make you touch them sexually? | Never/once/ more than once |
11. How often did anyone at least 5 years older than you or an adult force you to have sex? | Never/once/ more than once |