| RPT |
|.||Adverse Childhood Experiences (ACE)|
prevalence of physical and mental health risks.| |
Questions and Answers:|
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?| <*Answer_8460*>| |
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?| <*Answer_8461*>| |
| Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>|
3. Did an adult 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?| <*Answer_8462*>| |
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?| <*Answer_8463*>| |
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 |
Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>|
you to the doctor if you needed it?| <*Answer_8464*>| |
6. Were your parents ever separated or divorced?| <*Answer_8465*>| |
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 at least a few minutes or threatened|
with a gun or knife?| <*Answer_8466*>| |
8. Did you live with anyone who was a problem drinker or alcoholic or|
who used street drugs?| <*Answer_8467*>| |
9. Was a household member depressed or mentally ill, or did a house-|
SSN: <.Patient_SSN.>| DOB: <.Patient_Date_Of_Birth.> (<.Patient_Age.>)
hold member attempt suicide?| <*Answer_8467*>| |
10. Did a household member go to prison?| <*Answer_8469*>| |
Information contained in this note is based on a self-report assessment |
and is not sufficient to use alone for diagnostic purposes. Assessment |
results should be verified for accuracy and used in conjunction with |
other diagnostic activities.| |
$~
| Gender: <.Patient_Gender.>| |
ACE Total Score = <-Total Score->| |
Total scores range from 0 - 10. The higher the score, the higher the|
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