ACE 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]