ACE Survey ACE Survey While you were growing up, that is during your first 18 years of life… 1. Did you feel safe in your neighborhood? All of the time Most of the time Some of the time None of the time 2. Did you feel people in your neighborhood looked out for each other, stood up for each other, and could be trusted? All of the time Most of the time Some of the time None of the time 3. How often were you bullied by a peer or classmate? All of the time Most of the time Some of the time None of the time 4. How often, if ever did you see or hear someone being beaten up, stabbed, or shot in real life? Many times A few times Once Never Now please think about your childhood, in general, not just your neighborhood or community. FOR Q5-6: While you were growing up, during your first 18 years of life, how true were each of the following statements? 5. There was someone in your life who helped you feel important or special. Was this: Very often true Often true Sometimes true Rarely true Never true 6. Your family sometimes cut the size of meals or skipped meals because there was not enough money in the budget for food. Was this Very often true Often true Sometimes true Rarely true Never true Sometimes people are treated badly, not given respect, or are considered inferior because of the color of their skin, because they speak a different language or have an accent, or because they come from a different country or culture. 7. While you were growing up during your first 18 years of life how often did you feel that you were treated badly or unfairly because of your race or ethnicity? Very often true Often true Sometimes true Rarely true Never true 8. Did you live with anyone who was depressed or mentally ill? Yes No 9. Did you live with anyone who was suicidal? Yes No 10. Did you live with anyone who was a problem drinker or alcoholic? Yes No 11. Did you live with anyone who used illegal street drugs or who abused prescription medications? Yes No 12. Did you live with anyone who served time or was sentenced to serve time in a prison, jail, or other correctional facility? Yes No 13. Were you ever in foster care? Yes No Sometimes physical blows occur between parents or other adults in the house. While you were growing up, that is during your first 18 years of life… 14. How often, if ever, did you see or hear a parent, step parent or another adult who was helping to raise you being yelled at, screamed at, sworn at, insulted or humiliated? Many times A few times Once Never 15. How often, if ever, did you see or hear in your home a parent, step parent or another adult who was helping raise you being slapped, kicked, punched or beaten up? Many times A few times Once Never 16. How often, if ever, did you see or hear a parent, step parent or another adult who was helping to raise you being hit or cut with an object, such as a stick or cane, bottle, club, knife, or gun? Many times A few times Once Never While you were growing up, that is during your first 18 years of life, how often, if ever, did a parent, stepparent, or another adult living in your home… 17. Swear at you, insult you, or put you down? Many times A few times Once Never 18. Push, grab, shove, or slap you? Many times A few times Once Never 19. Hit you so hard that you had marks or were injured? Many times A few times Once Never 20. Act in a way that made you afraid that you would be physically hurt? Many times A few times Once Never Some people, while growing up in their first 18 years of life, had a sexual experience with an adult or someone at least five years older than themselves. These experiences may have involved a relative, family friend, or stranger. During the first 18 years of life, did an adult or older relative, family friend or stranger who was at least five years older than yourself ever…? 21. Touch or fondle you in a sexual way or have you touch their body in a sexual way? Yes No 22. Attempt to have or actually have any type of sexual intercourse, oral, anal, or vaginal, with you? Yes No We are almost done with the survey but have a few more questions about your health and well-being over your entire lifetime. Have you EVER been told by a doctor or other health professional that you have or had any of these medical conditions or illnesses? How about…? 23. Angina, coronary heart disease, or a heart attack also called a myocardial infarction? Yes No 24. A stroke or “small stroke?” Yes No 25. Chronic bronchitis or emphysema? Yes No 26. Broken any bones? Yes No 27. Yellow jaundice, hepatitis, or any liver trouble? Yes No 28. A sexually transmitted infection, such as chlamydia, gonorrhea, syphilis, or trichamoniasis (also known as Trich)? Yes No Our next few questions are about your sexual relationships and practices. Remember that your answers will be kept strictly confidential. When we talk about a sex partner, we mean any person, male or female, with whom you had sex, even if it was just once. By sex, we mean oral sex, vaginal sex, or anal sex. The next questions are about your VOLUNTARY sex experiences. 29. How old were you the first time you had sex? 31. How many different sex partners have you ever had? Remember, we are talking about people you had oral, vaginal or anal sex with. If you don’t know the exact number, please give your best estimate. Five or fewer Six to ten Eleven to 29 Thirty or more sexual partners 32. Female: Have you ever been pregnant? Male: Have you ever gotten someone pregnant? Yes No 33. Female: When your first pregnancy began, did you intend to get pregnant at that time in your life?/ Male: When you got someone pregnant for the first time, did you intend to get them pregnant at that time in your life? Yes No 34. Female: How old were you when you first became pregnant?/ Male: How old were you when you first got someone pregnant? Now, a few questions about various personal health behaviors. 35. Have you ever used or injected illicit drugs, such as marijuana, cocaine, including crack, hallucinogens, inhalants, heroin, or prescription drugs that were not prescribed for you, including OxyContin, Xanax, or Adderall? Yes No 36. In the past year, have you had two or more weeks of being in a depressed mood, that is feeling down, depressed, or hopeless, or had little interest in doing things? Yes No 37. Have you ever attempted to commit suicide? Yes No And now, a couple general questions: 38. Did you grow up in the city of Philadelphia? Yes No 39. What State did you grow up in? 40. And what city or county did you grow up in? Baltimore, MD Boston, MA Camden, NJ Chicago, IL Las Vegas, NV Los Angeles, CA New York, NJ Newark, NJ Norristown, PA Seattle, WA Trenton, NJ Wilmington, DE Washington, DC OtherOther Moved around all of the time – didn’t grow up any particular city or county If you are human, leave this field blank. Submit Start Over