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Make an Appointment
Patient Portal
Insurance & Billing
Medical Records
On-Site Amenities & Dining Options
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Gift Shop
University Pharmacy
Locations
Parking & Directions
Patient Experience
Medical Care
Medical Services
Find A Doctor
UT Urgent Care
Regional Health Centers
Specialty Practices
Directory of Services
Department Directory
Procedures & Treatments
Centers of Excellence
Brain & Spine Institute
Cancer Institute
Emergency & Trauma Center
Heart Lung Vascular Institute
Orthopaedic Institute
Primary Care Collaborative
Center for Women & Infants
Academics & Research
Academic Medical Center
Graduate School of Medicine
Pharmacy Residency Programs
School of Computerized Tomography
School of Medical Laboratory Science
School of Radiography
School of Vascular Interventional Radiography
Research
Clinical Trials
Health Care Professionals
Referring Physicians
Nursing Excellence
Careers
Education & Training
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About
Our Story
Excellence & Achievements
UT Medical Center’s Mission, Vision and Values
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Internal Medicine-Adverse Childhood Experiences
Forms Directory
Internal Medicine-Adverse Childhood Experiences
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While you were growing up, during your first 18 years of life...
1. Did a parent or other adult in the household often swear at you, insult you, put you down, or humiliate you? or Act in a way that made you afraid that you might be physically hurt?
*
Yes
No
2. Did a parent or other adult in the household often push, grab, slap, or throw something at you? or Ever hit you so hard you had marks or were injured?
*
Yes
No
3. Did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way? or Try to actually have oral, anal, or vaginal sex with you?
*
Yes
No
4. Did you often feel that no one in your family loved you or thought you were important or speical? or Your familiy didn't look out for each other, feel close to each other, or support each other?
*
Yes
No
5. Did you often feel that you didn't have enough to eat, had to wear dirty clothes, and had no one to protect you? or Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?
*
Yes
No
6. Were your parents ever separated or divorced?
*
Yes
No
7. Was your mother or stepmother often pushed, grabbed, slapped, or had something thrown at her? or Sometimes or often kicked, bitten, hit with a fist, or hit with something hard? or Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?
*
Yes
No
8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?
*
Yes
No
9. Was a household member depressed or mentally ill or did a household member attempt suicide?
*
Yes
No
10. Did a household member go to prison?
*
Yes
No
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