ACE (Adverse Childhood Experiences) Screening

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.