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    Dr. Zenobia Bass

"Self-Care is the key to living a peaceful, joyful and purposeful life!"

Smile...come on, you can do it, SMILE and Embrace your Greatness

Adverse Childhood Experience (ACE) Questionnaire

Finding your ACE Score (http://www.cdc.gov/violenceprevention/acestudy)

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household 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

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

Try to or actually have oral, anal, or vaginal sex with you?

Yes No If yes enter 1 ________

4. Did you 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 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. Were your parents ever separated or divorced?

Yes No If yes enter 1 ________

7. Was your mother or stepmother:

Often pushed, grabbed, slapped, or had something thrown at her?

                                                      or

Sometimes or 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

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Office: 678-514-2181 Cell: 404-808-4193