The ACE questionnaire asks about ten kinds of adversity in the first 18 years of life: abuse, neglect, and challenges in the household. The ACE score is how many of the ten a person lived through, from 0 to 10. See what the ten categories are, what a score means, how to talk about it with care, and record the result with the free template. The official form comes from its source.
ACE questionnaire result template
FreeACE QUESTIONNAIRE RECORD Date: [Date] Patient: [Name or chart number, age] Visit type: [Wellness visit, new patient, chronic condition review, prenatal visit, or behavioral health intake] Clinician: [Name, credentials] HOW IT WAS DONE Version used: [Name of the adult ACE questionnaire your clinic uses] Format: [Total only, or item-level with the categories marked] Completed: [Alone on paper, on a tablet in a private room, or read aloud on request; language and interpreter if used] Earlier ACE screen: [Date and score, or first time] SCORE ACE score: [0 to 10 categories] Range: [None reported 0, some adversity 1 to 3, or high 4 to 10] Categories: [Only those the person agreed to record, or total only] ACE-associated conditions: [Present now, such as chronic pain, depression, anxiety, asthma, heart disease, or substance use; or none] CONVERSATION How it was raised: [Permission asked; told that no details are needed] Their response: [What the person said about the score and its effect on them, in their words] Strengths and supports: [Safe adults growing up, supportive people now, coping that works] Safety now: [Violence or threats at home at present, asked in private] HEALTH LINKS Discussed: [How long-term stress can affect sleep, pain, mood, and heart and metabolic health] Buffers: [Sleep, movement, nutrition, mindfulness, relationships, and mental health care] RESOURCES AND PLAN Offered: [Therapy referral, behavioral health in the practice, community or peer support, the 988 line] Chosen: [What the person accepted, and what they declined for now] Follow-up: [Next visit, referral check, and when to revisit the topic] Signed: [Clinician name, credentials]
Use it for
Screen only when you can respond. Decide who reviews the score, what you can offer, and where you refer, before the first patient fills it in.
Avoid: Screening with no plan for what happens next. Asking about abuse and then moving straight on can leave a person feeling exposed.
The person fills it in alone, in a few minutes, thinking about the first 18 years of their life.
Avoid: Reading the questions aloud in a shared room, or asking for the story behind each yes.
Count the categories answered yes. Each counts once, for a score from 0 to 10.
Avoid: Adding other adversities to the total. The score’s research links rest on the original ten categories.
The conversation matters more than the number. Ask before you talk about it, and let the person lead.
Avoid: Telling someone with a high score that they are likely to get sick. Present it as a reason for support, not a forecast.
The response follows the score, the person’s health, and what they want: education for everyone, and more support where it’s needed.
Avoid: Making a referral the person didn’t agree to. Offer, record the choice, and leave the door open.
Each one follows the recording template. Use them to judge how much to write.
Family practice, new patient visit, filled in on a tablet in a private exam room
Clinic’s adult ACE questionnaire, total-only format, in English. Filled in alone before the clinician came in. First ACE screen.
36-year-old woman. ACE score 5, high. Total only; she chose not to mark categories. ACE-associated conditions: low back pain for 6 years, and anxiety, with a GAD-7 of 14 today.
Asked whether she wanted to talk about the score; she did, briefly. Said home was “loud and unpredictable” and she left at 17; told her no details were needed and she shared none. She said she’d never linked it to her health. Strengths: close to her older sister, runs with a group on weekends, steady work as a dental hygienist. Lives with her partner and feels safe at home.
Explained that years of stress in childhood can keep the body’s stress response switched on, which is linked to chronic pain, poor sleep, and anxiety, and that this is common and responds to care. Running, sleep, and her sister’s support named as buffers she already has.
Offered a referral to a trauma-informed therapist for anxiety; accepted. Offered the practice’s behavioral health clinician today; declined for now. Physical therapy for her back continues. 988 for a crisis. Review pain and anxiety in 4 weeks, and ask whether the first therapy session has happened.
Internal medicine clinic, annual check-up, paper form filled in before the visit
Clinic’s adult ACE questionnaire, item-level format, in English. Filled in alone in the waiting room and handed to the medical assistant in an envelope. First ACE screen.
52-year-old man. ACE score 1, some adversity. He marked one category, parental separation or divorce, and was happy for it to be noted. ACE-associated conditions: none; blood pressure 124/78 mm Hg, no depression, anxiety, or chronic pain.
Asked how the questions felt; he said fine. His parents divorced when he was 12; he lived with his mother and stayed close to his father. Strengths: married 22 years, coaches his daughter’s soccer team, walks most evenings. Safe at home.
Brief talk on how stress in childhood and adult life can affect health, and on what protects it: his relationships, exercise, and sleep.
No referral needed or wanted. Told him he can raise anything from childhood at any visit. No need to repeat the questionnaire. Routine screening continues; next wellness visit in a year.
A score of 6 with nothing offered beside it can feel like being asked and then ignored. Have resources and a referral path ready before you start.
An ACE score measures exposure across a population. Many people with high scores stay well, and many with low scores don’t. Use it to start a conversation, not to predict an outcome.
The total is enough. Asking what happened in each category can retraumatize, and it isn’t needed to respond well.
If they chose the total only, record the total only. Their choice about what goes in the chart is part of a trauma-informed approach.
The ten categories leave out racism, poverty, community violence, and much more, and some people don’t disclose the first time. Leave the door open.
Vero Scribe records the ACE result in your template from the visit, with the patient’s consent, or from your dictation: the score, how it was discussed, the person’s strengths, and what they chose. You review and edit every line, then copy it into your record. Vero works in 60+ languages.
Count the categories answered yes. Each of the ten counts once, however often or long it happened, for a score from 0 to 10. A person can give just the total, without saying which categories apply.
Three kinds of abuse: emotional, physical, and sexual. Two kinds of neglect: emotional, such as not feeling loved or supported, and physical, such as not having food, clean clothes, safety, or care. And five household challenges: a mother or stepmother treated violently, someone in the home misusing alcohol or drugs, someone in the home with a mental illness or a suicide attempt, parents separated or divorced, and a household member in jail or prison.
Four or more. That is the level most research links to much higher risk of depression, substance use, suicide attempts, and heart and lung disease. In the original study, about 1 in 8 adults scored 4 or more, and about two in three reported at least one category.
It counts how many kinds of adversity you lived through before 18. It isn’t a diagnosis and doesn’t predict your future: many people with high scores do well, especially with safe, supportive relationships. A higher score is a reason to talk with a clinician about stress, health, and support.
Yes. It’s a self-report questionnaire, and versions are free online. The questions can bring up painful memories, so take it when you have support, and talk the result through with a clinician or therapist. If you feel unsafe, call or text 988.
The ACE questionnaire counts kinds of adversity in childhood. A PTSD screen, such as the PC-PTSD-5, asks about symptoms now after a traumatic event at any age. A person can have a high ACE score and no PTSD, or PTSD and a score of 0.
The person usually fills it in alone, so any trained member of the care team can hand it out. A clinician who can respond, such as a physician, nurse practitioner, or therapist, should review and discuss the score.
Yes. Pediatric versions include the PEARLS and the Center for Youth Wellness ACE-Q, filled in by a parent or caregiver, or by teens themselves.
Yes. The CDC says the original study questionnaires are not copyrighted and have no fees. Clinic versions, such as the adult ACE questionnaire from ACEs Aware, are free to download under their source’s terms. The recording template on this page is free to copy or download too.
Nine questions on the last two weeks: depression screening and severity, scored 0 to 27.
Two questions on interest and mood: a quick first screen for depression, scored 0 to 6.
Seven questions on worry and tension: anxiety screening and severity, scored 0 to 21.
Up to six questions on suicidal thoughts and behavior; the highest yes sets low, moderate, or high risk.
Twenty items on the past month: PTSD screening and symptom tracking, scored 0 to 80.
The first session, with the trauma screen and the ACE score in the history.
For a high score: childhood, health, relationships, and strengths in one assessment.
Wellness visits, chronic care, and screening results written up from the visit.
Every tool, by area, with what its scores mean.
Vero records scores, findings, and plans in the templates you choose, so you review instead of type.
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