Adverse Childhood Experiences Emotional Abuse How often in your life have your parents or other adults in your household insulted or degraded you? Never, rarely, sometimes, most of the time, or always yes ( Physical Abuse In your life, how often did a parent or other adult in your household hit, punch, kick, or Did you physically hurt yourself? Never, Rarely, Sometimes, Most of the Time, or Always Yes (rarely, sometimes, most of the time, or always) and No (never) Sexual Abuse Forcible sexual abuse by an adult or someone at least 5 years older than you Have you ever been sexually abused? Did you do something sexual that you didn’t want to do? (Counts being kissed, touched, forced to have sex, etc.) Yes or No Yes or No Physical Neglect In your life, trying hard to make sure your basic needs are met. How many adults in your family have made an effort to Did you take care of yourself, make sure you had clean clothes and enough food? Never, Rarely, Sometimes, Most of the Time, or Always Yes (Never, or Rarely) vs. No (Sometimes, Most of the Time, Always)* Have you witnessed violence by an intimate partner in your life? How often have adults witnessed violence in your home? Have you been hit, punched, kicked, punched, or punched? Never, Rarely, Sometimes, Most of the Time, or Always Yes (rarely, sometimes, most of the time, or always) vs. No (never) Household Substance Use Alcohol or drug use? Yes or No Yes vs No Poor mental health in your household Do you have severe depression, anxiety, or other mental illness? , or have you ever lived with a suicidal parent or guardian? Yes or No Yes vs. No Parent or guardian was incarcerated or incarcerated Parent or guardian was sent to jail, prison, or jail Have you ever been separated from someone? Yes or No Yes vs No Cumulative ACE Count Cumulative ACE Count = (Emotional Abuse + Physical Abuse + Sexual Abuse + Physical Neglect + Witnessed IPV + Domestic Substance Use + Home of poor mental health + incarcerated parent or guardian) Total possible number is 8 † For classified ACEs: 0, 1, 2 or 3, or 4 or more Health outcomes or risk behaviors Past 30 days How many days in the past 30 days did you carry a weapon, such as a gun, knife, etc., to school? Or to a club on school grounds? 0 days, 1 day, 2-3 days, 4-5 days, or 6+ days Yes (1 day, 2-3 days, 4-5 days, or 6+ days) vs. No (0 days) in the past 12 months How many fights have you had in the past 12 months? 0, 1, 2-3, 4-5, 6-7, 8-9, 10-11, or 12 More than once (1 time, 2-3 times, 4-5 times, 6-7 times, 8-9 times, 10-11 times, or 12 or more times) and not used (0 times) in the past 30 days Current E-vapor Product Use In the past 30 days, how many days have you used an e-vapor product? 0 days, 1-2 days, 3-5 days, 6-9 days, 10-19 days, 20 – 29 days, or all 30 days Yes (1-2 days, 3-5 days, 6-9 days, 10-19 days, 20-29 days, or all 30 days) and None (0 days) For the past 30 days Current Alcohol Consumption On how many days in the past 30 days did you consume at least one drink of alcohol? 0 days, 1-2 days, 3-5 days, 6-9 days, 10-19 days, 20-29 days, or all 30 days Yes (1-2 days, 3-5 days, 6-9 days, 10 −19 days, 20-29 days, or all 30 days) and none (0 days) Current binge drinking in the past 30 days How many days in the past 30 days did you have 4 or more drinks of alcohol in a row? mosquito. i.e. within a few hours (for women) or 5 or more drinks of alcohol in a row i.e. within 2 hours (for men)? 0 days, 1 day, 2 days, 3-5 days, 6 ~9 days, 10-19 days, or 20+ days Yes (1 day, 2 days, 3-5 days, 6-9 days, 10-19 days), or ≥20 days) and No (0 days) Last 30 Current Prescription Opioid Misuse in Days In the past 30 days, how many times have you taken a prescription pain medication without a doctor’s prescription or in a manner different from your doctor’s instructions? 0 times, 1-2 times, 3-9 times, 10-19 times, 20-39 times, or 40 or more times Yes (1-2 times, 3-9 times, 10-19 times, 20-39 times, or ≥40 times) vs. none (0 times) Alcohol or drug use before last intercourse Did you drink alcohol or use drugs before your last intercourse? I have never had intercourse, yes , or No Yes or No (No or I have never had sex) Currently, I have had sex with more than one person in the past 3 months How many people have I had sex with in the past 3 months? No, I have had sex but not in the past 3 months, 1, 2, 3, 4, 5, or 6 or more Yes (2, 3, 4), 5, or 6 or more people) vs No (have never had sex, have had sex but not in the past 3 months, or 1 person) Did not use a condom the last time you had sex Last time you had sex, you Or did your partner use a condom? Never had sex, yes, or no Yes (no (didn’t use a condom)) and no (yes (did use a condom) or had sex ) Underweight How tall are you without shoes? How much do you weigh without shoes? Enter your height in feet and inches. Weight (lbs) Calculated using self-reported height and weight BMI <5th percentile § Overweight or obese How tall are you without shoes? How much do you weigh without shoes Enter your height in feet and inches. Weight (lbs) Calculated using self-reported height and weight with BMI at or above the 85th percentile § Self-identified as underweight How would you describe your weight? Very thin, Slightly underweight, about normal weight, slightly overweight, or very overweight Self-perceived underweight (very underweight or slightly underweight) and self-perceived “about right” weight Self-perceived How would you describe your weight? Very underweight, slightly underweight, about normal weight, slightly overweight, or very overweight Self-perception Overweight (slightly overweight or very overweight) and self-perceived "nearly normal" weight Persistent feelings of sadness or hopelessness in the past 12 months Very sad almost every day for more than two consecutive weeks in the past 12 months Have you ever stopped your normal activities because you felt so hopeless? Yes or No Yes vs No In the past 12 months, have you seriously considered attempting suicide? In the past 12 months, have you seriously considered attempting suicide? Have you seriously considered it? Yes or No Yes vs. No Have you attempted suicide in the past 12 months How many times have you actually attempted suicide in the past 12 months? 0, 1, 2-3 times , 4-5 times, or ≥6 times Yes (1 time, 2-3 times, 4-5 times, or ≥6 times) vs. No (0 times)
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