Childhood Adversity Screening and Health Impact Review

Client name: Marcus Vance

1. Did you frequently lack sufficient food, have to wear unclean clothing, or have no one to safeguard or care for you? [ ]

2. Did you lose a parent because of divorce, abandonment, death, or another circumstance? [x]

3. Did you live with someone who was depressed, had a mental illness, or attempted suicide? [x]

4. Did you live with someone who had a drinking or drug-use problem, including misuse of prescription drugs? [x]

5. Did your parents or other adults in your home ever hit, punch, beat, or threaten each other with harm? [ ]

6. Did you live with someone who was incarcerated? [ ]

7. Did a parent or other adult in your home frequently swear at, insult, or demean you? [x]

8. Did a parent or other adult in your home ever hit, beat, kick, or otherwise physically harm you? [ ]

9. Did you frequently feel that no one in your family loved you or considered you special? [x]

10. Did you experience any unwanted sexual contact (for example, fondling or oral, anal, or vaginal intercourse or penetration)? [ ]

Total ACE Score: 5

Follow-Up Questions

• Do you feel that these experiences have affected your overall health?
  • Not Much [ ]
  • Some [ ]
  • A Lot [x]