{"id":290,"date":"2025-07-19T22:38:24","date_gmt":"2025-07-19T22:38:24","guid":{"rendered":"https:\/\/evolvetofitness.com\/?page_id=290"},"modified":"2025-07-19T22:38:25","modified_gmt":"2025-07-19T22:38:25","slug":"adverse-childhood-experience-questionnaire-for-adults","status":"publish","type":"page","link":"https:\/\/evolvetofitness.com\/index.php\/adverse-childhood-experience-questionnaire-for-adults\/","title":{"rendered":"Adverse Childhood Experience Questionnaire for Adults"},"content":{"rendered":"<style id=\"wpforms-css-vars-254-block-f90b0c5d-74b1-4dfb-8412-bf636f603173\">\n\t\t\t\t#wpforms-254.wpforms-block-f90b0c5d-74b1-4dfb-8412-bf636f603173 {\n\t\t\t\t--wpforms-label-color: #3d3835;\n--wpforms-label-sublabel-color: #79716b;\n--wpforms-label-error-color: #edb254;\n--wpforms-page-break-color: #ef8225;\n--wpforms-field-border-color: #cbc6c2;\n--wpforms-field-border-color-spare: #cbc6c2;\n--wpforms-field-text-color: #3d3835;\n--wpforms-container-border-radius: 0px;\n--wpforms-button-background-color: #111111;\n--wpforms-button-text-color: #edb254;\n--wpforms-button-border-color: #ff4500;\n--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n--wpforms-container-shadow-size-box-shadow: none;\n\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-block wpforms-block-f90b0c5d-74b1-4dfb-8412-bf636f603173 wpforms-render-modern\" id=\"wpforms-254\"><form id=\"wpforms-form-254\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"254\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/290\" data-token=\"b694dc362ed53ea65ab4a537f720d837\" data-token-time=\"1780192395\"><div class=\"wpforms-head-container\"><div class=\"wpforms-description\">Our relationships and experiences\u2014even those in childhood\u2014can affect our health and\r\nwell-being. Difficult childhood experiences are very common. Please tell us whether you\r\nhave had any of the experiences listed below, as they may be affecting your health today or\r\nmay affect your health in the future. This information will help you and your provider better\r\nunderstand how to work together to support your health and well-being.<\/div><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div id=\"wpforms-error-noscript\" style=\"display: none;\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-254-field_1-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"1\"><div id=\"wpforms-254-field_1\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-254-field_1-error\"><p>Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From<br \/>\nthe list below, please place a checkmark next to each ACE category that you experienced<br \/>\nprior to your 18th birthday. Then, please add up the number of categories of ACEs you<br \/>\nexperienced and put the total number at the bottom.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-254-field_12-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"12\"><fieldset><legend class=\"wpforms-field-label\">Checkboxes<\/legend><ul id=\"wpforms-254-field_12\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_1\" name=\"wpforms[fields][12][]\" value=\"Did you feel that you didn\u2019t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?\" aria-errormessage=\"wpforms-254-field_12_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_1\">Did you feel that you didn\u2019t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_2\" name=\"wpforms[fields][12][]\" value=\"Did you lose a parent through divorce, abandonment, death, or other reason?\" aria-errormessage=\"wpforms-254-field_12_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_2\">Did you lose a parent through divorce, abandonment, death, or other reason?<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_3\" name=\"wpforms[fields][12][]\" value=\"Did you live with anyone who was depressed, mentally ill, or attempted suicide?\" aria-errormessage=\"wpforms-254-field_12_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_3\">Did you live with anyone who was depressed, mentally ill, or attempted suicide?<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_4\" name=\"wpforms[fields][12][]\" value=\"Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?\" aria-errormessage=\"wpforms-254-field_12_4-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_4\">Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_5\" name=\"wpforms[fields][12][]\" value=\"Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?\" aria-errormessage=\"wpforms-254-field_12_5-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_5\">Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_6\" name=\"wpforms[fields][12][]\" value=\"Did you live with anyone who went to jail or prison?\" aria-errormessage=\"wpforms-254-field_12_6-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_6\">Did you live with anyone who went to jail or prison?<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_7\" name=\"wpforms[fields][12][]\" value=\"Did a parent or adult in your home ever swear at you, insult you, or put you down?\" aria-errormessage=\"wpforms-254-field_12_7-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_7\">Did a parent or adult in your home ever swear at you, insult you, or put you down?<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_8\" name=\"wpforms[fields][12][]\" value=\"Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?\" aria-errormessage=\"wpforms-254-field_12_8-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_8\">Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_9\" name=\"wpforms[fields][12][]\" value=\"Did you feel that no one in your family loved you or thought you were special?\" aria-errormessage=\"wpforms-254-field_12_9-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_9\">Did you feel that no one in your family loved you or thought you were special?<\/label><\/li><li class=\"choice-10 depth-1\"><input type=\"checkbox\" id=\"wpforms-254-field_12_10\" name=\"wpforms[fields][12][]\" value=\"Did you experience unwanted sexual contact (such as fondling or oral\/anal\/vaginal intercourse\/penetration)?\" aria-errormessage=\"wpforms-254-field_12_10-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_12_10\">Did you experience unwanted sexual contact (such as fondling or oral\/anal\/vaginal intercourse\/penetration)?<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-254-field_13-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-254-field_13\">Your ACE score is the total number of checked responses:<\/label><input type=\"number\" id=\"wpforms-254-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" step=\"any\" aria-errormessage=\"wpforms-254-field_13-error\" ><\/div><div id=\"wpforms-254-field_7-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"7\"><fieldset><legend class=\"wpforms-field-label\">Do you believe that these experiences have affected your health?<\/legend><ul id=\"wpforms-254-field_7\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-254-field_7_1\" name=\"wpforms[fields][7]\" value=\"Not Much\" aria-errormessage=\"wpforms-254-field_7_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_7_1\">Not Much<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-254-field_7_2\" name=\"wpforms[fields][7]\" value=\"Some\" aria-errormessage=\"wpforms-254-field_7_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_7_2\">Some<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-254-field_7_3\" name=\"wpforms[fields][7]\" value=\"A lot\" aria-errormessage=\"wpforms-254-field_7_3-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-254-field_7_3\">A lot<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-254-field_8-container\" class=\"wpforms-field wpforms-field-content\" data-field-id=\"8\"><div id=\"wpforms-254-field_8\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-254-field_8-error\"><p>Experiences in childhood are just one part of a person\u2019s life story.<br \/>\nThere are many ways to heal throughout one\u2019s life.<br \/>\nPlease let us know if you have questions about privacy or confidentiality.<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-254-field_9-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-254-field_9\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][9][first]\" aria-errormessage=\"wpforms-254-field_9-error\" required><label for=\"wpforms-254-field_9\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-254-field_9-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][9][last]\" aria-errormessage=\"wpforms-254-field_9-last-error\" required><label for=\"wpforms-254-field_9-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div>\t\t<div id=\"wpforms-254-field_2-container\"\n\t\t\tclass=\"wpforms-field wpforms-field-text\"\n\t\t\tdata-field-type=\"text\"\n\t\t\tdata-field-id=\"2\"\n\t\t\t>\n\t\t\t<label class=\"wpforms-field-label\" for=\"wpforms-254-field_2\" >is Do experiences<\/label>\n\t\t\t<input type=\"text\" id=\"wpforms-254-field_2\" class=\"wpforms-field-medium\" name=\"wpforms[fields][2]\" >\n\t\t<\/div>\n\t\t<div id=\"wpforms-254-field_14-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-254-field_14\">Date <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-254-field_14\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][14][date]\" aria-errormessage=\"wpforms-254-field_14-error\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-254-field_10-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-254-field_10\">Email <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"email\" id=\"wpforms-254-field_10\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][10]\" spellcheck=\"false\" aria-errormessage=\"wpforms-254-field_10-error\" required><\/div><div id=\"wpforms-254-field_11-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-254-field_11\">Phone <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-254-field_11\" class=\"wpforms-field-medium wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][11]\" aria-label=\"Phone\" aria-errormessage=\"wpforms-254-field_11-error\" required><\/div><script>\n\t\t\t\t( function() {\n\t\t\t\t\tconst style = document.createElement( 'style' );\n\t\t\t\t\tstyle.appendChild( document.createTextNode( '#wpforms-254-field_2-container { position: absolute !important; overflow: hidden !important; display: inline !important; height: 1px !important; width: 1px !important; z-index: -1000 !important; padding: 0 !important; } #wpforms-254-field_2-container input { visibility: hidden; } #wpforms-conversational-form-page #wpforms-254-field_2-container label { counter-increment: none; }' ) );\n\t\t\t\t\tdocument.head.appendChild( style );\n\t\t\t\t\tdocument.currentScript?.remove();\n\t\t\t\t} )();\n\t\t\t<\/script><\/div><!-- .wpforms-field-container --><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"254\"><input type=\"hidden\" name=\"page_title\" value=\"\"><input type=\"hidden\" name=\"page_url\" value=\"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/pages\/290\"><input type=\"hidden\" name=\"url_referer\" value=\"\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-254\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/evolvetofitness.com\/wp-content\/plugins\/wpforms\/assets\/images\/submit-spin.svg\" class=\"wpforms-submit-spinner\" style=\"display: none;\" width=\"26\" height=\"26\" alt=\"Loading\"><\/div><\/form><\/div>  <!-- .wpforms-container -->","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"om_disable_all_campaigns":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/pages\/290"}],"collection":[{"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/comments?post=290"}],"version-history":[{"count":1,"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/pages\/290\/revisions"}],"predecessor-version":[{"id":291,"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/pages\/290\/revisions\/291"}],"wp:attachment":[{"href":"https:\/\/evolvetofitness.com\/index.php\/wp-json\/wp\/v2\/media?parent=290"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}