ACE (Adverse Childhood Experiences) Screening
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ACE (Adverse Childhood Experiences) Screening
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The ACE (Adverse Childhood Experiences) Screening form digitizes the 10-item ACE questionnaire developed from the landmark CDC-Kaiser Permanente ACE Study, one of the largest investigations into the relationship between childhood adversity and long-term health outcomes. The ten questions assess exposure before age 18 to abuse (emotional, physical, sexual), neglect (emotional, physical), and household dysfunction (domestic violence, substance abuse, mental illness, parental separation, and incarcerated household member).
Each affirmative response adds one point to the ACE score, which ranges from 0 to 10. Research has demonstrated a powerful dose-response relationship between ACE scores and adult health risks: individuals with an ACE score of 4 or higher face significantly elevated risks for chronic diseases, mental health disorders, substance use disorders, and reduced life expectancy. The digital form provides automatic score calculation and risk-tier interpretation to help clinicians contextualize the results within a trauma-informed care framework.
This template is designed for use in primary care practices implementing trauma-informed approaches, behavioral health and therapy intakes, pediatric and family medicine settings, and community health programs. The form uses sensitive, non-judgmental language and includes a trauma response disclaimer that explains the purpose of the screening and provides crisis resources. Providers can use the ACE score alongside resilience assessments to develop comprehensive, strengths-based treatment plans.
What's included
- All 10 validated ACE questionnaire items
- Automatic ACE score calculation and risk-tier mapping
- Sensitive, non-judgmental question language
- Trauma response disclaimer and crisis resources
- Resilience factor assessment section
- Provider notes for trauma-informed care planning
Who uses this template
- Behavioral health and therapy intake assessments
- Primary care trauma-informed care screening
- Pediatric and family medicine risk evaluation
- Community health and social service programs
All form fields
14 fields across 2 pages. Customize any field after signing up.
How to use the ACE (Adverse Childhood Experiences) Screening
Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the ACE (Adverse Childhood Experiences) Screening from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.
Setup steps
- 1Choose the template. Find the ACE (Adverse Childhood Experiences) Screening in the template library and click “Use this template” to add it to your account.
- 2Customize fields. Add, remove, or reorder any of the 14 fields. Set fields as required or optional based on your practice needs.
- 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
- 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
- 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.
Frequently asked questions
Is the ACE (Adverse Childhood Experiences) Screening HIPAA compliant?
Yes. All Formisoft templates, including the ACE (Adverse Childhood Experiences) Screening, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.
Can I customize the fields in this template?
Absolutely. You can add, remove, reorder, or modify any of the 14 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.
How do patients fill out this form?
Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.
Can I send this form automatically before appointments?
Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.
Does this template work on mobile devices?
Yes. The ACE (Adverse Childhood Experiences) Screening is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.
Start with this template
Sign up and start customizing the ACE (Adverse Childhood Experiences) Screening for your practice. Set up in minutes.
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