112441-1
Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults]
Active
Form Coding Instructions
Instructions: Below is a list of 10 categories of Adverse Childhood Experiences (ACEs). From the list below, please add up the number of categories of ACEs you experienced prior to your 18th birthday and put the total number at the bottom. (You do not need to indicate which categories apply to you, only the total number of categories that apply.)
Source: Office of the California Surgeon General and the Department of Health Care Services, in consultation with the ACEs Aware Clinical Advisory Subcommittee112462-7 Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you?
Observation ID in Form
Q1
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did you feel that you didn't have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did you feel that you didn't have enough to eat, had to wear dirty clothes, or had no one to protect or take care of you
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112461-9 Did you lose a parent through divorce, abandonment, death, or other reason?
Observation ID in Form
Q2
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did you lose a parent through divorce, abandonment, death, or other reason
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did you lose a parent through divorce, abandonment, death, or other reason
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112459-3 Did you live with anyone who was depressed, mentally ill, or attempted suicide?
Observation ID in Form
Q3
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did you live with anyone who was depressed, mentally ill, or attempted suicide
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did you live with anyone who was depressed, mentally ill, or attempted suicide
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112457-7 Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs?
Observation ID in Form
Q4
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did you live with anyone who had a problem with drinking or using drugs, including prescription drugs
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112455-1 Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other?
Observation ID in Form
Q5
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did your parents or adults in your home ever hit, punch, beat, or threaten to harm each other
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112453-6 Did you live with anyone who went to jail or prison?
Observation ID in Form
Q6
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did you live with anyone who went to jail or prison
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did you live with anyone who went to jail or prison
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112452-8 Did a parent or adult in your home ever swear at you, insult you, or put you down?
Observation ID in Form
Q7
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did a parent or adult in your home ever swear at you, insult you, or put you down
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did a parent or adult in your home ever swear at you, insult you, or put you down
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112451-0 Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way?
Observation ID in Form
Q8
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112445-2 Did you feel that no one in your family loved you or thought you were special?
Observation ID in Form
Q9
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Did you feel that no one in your family loved you or thought you were special
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did you feel that no one in your family loved you or thought you were special
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112444-5 Did you experience unwanted sexual contact?
Observation ID in Form
Q10
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Form Coding Instructions
such as fondling or oral/anal/vaginal intercourse/penetration
Source: Office of the California Surgeon General and the Department of Health Care Services, in consultation with the ACEs Aware Clinical Advisory SubcommitteeFully-Specified Name
- Component
- Did you experience unwanted sexual contact
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Did you experience unwanted sexual contact
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL5955-1
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Yes Copyright http://snomed.info/sct ID:373066001 Yes (qualifier value) | 1 | LA33-6 | |
| No Copyright http://snomed.info/sct ID:373067005 No (qualifier value) | 0 | LA32-8 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Third Party Copyright
This material includes SNOMED Clinical Terms® (SNOMED CT®) which is used by permission of the International Health Terminology Standards Development Organisation (IHTSDO) under license. All rights reserved. SNOMED CT® was originally created by The College of American Pathologists. "SNOMED" and "SNOMED CT" are registered trademarks of the IHTSDO.
This material includes content from the US Edition to SNOMED CT, which is developed and maintained by the U.S. National Library of Medicine and is available to authorized UMLS Metathesaurus Licensees from the UTS Downloads site at https://uts.nlm.nih.gov.
Use of SNOMED CT content is subject to the terms and conditions set forth in the SNOMED CT Affiliate License Agreement. It is the responsibility of those implementing this product to ensure they are appropriately licensed and for more information on the license, including how to register as an Affiliate Licensee, please refer to https://www.snomed.org/get-snomed or [email protected]<mailto:[email protected]>. This may incur a fee in SNOMED International non-Member countries.
112442-9 Total score [ACE Questionnaire for Adults]
Term Description
Add together the individual scores for all ten items. The total score should be between 0 and 10.
Observation Required in Panel
Required
Type of Entry
Question - computer calculates response [C]
Form Coding Instructions
How many "Yes" did you answer?
Source: Office of the California Surgeon General and the Department of Health Care Services, in consultation with the ACEs Aware Clinical Advisory SubcommitteeFully-Specified Name
- Component
- Total score
- Property
- Score
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Qn
- Method
- ACE Questionnaire for Adults
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |
Example Units
| Unit | Source |
|---|---|
| {score} | Example UCUM Units |
112443-7 Do you believe that these experiences have affected your health?
Observation Required in Panel
Required
Type of Entry
Question expects user entry - requires response [Q]
Fully-Specified Name
- Component
- Do you believe that these experiences have affected your health
- Property
- Find
- Time
- RptPeriod
- System
- ^Patient
- Scale
- Ord
- Method
Long Common Name
Do you believe that these experiences have affected your health
Basic Attributes
- Class
- SURVEY.SDOH
- Type
- Surveys
- First Released
- Version 2.82
- Last Updated
- Version 2.82 (ADD)
- Order vs. Observation
- Observation
Example Answer List LL7521-9
| Answer | Code | Score | Answer ID |
|---|---|---|---|
| Not much | LA37074-4 | ||
| Some | LA14973-4 | ||
| A lot | LA14468-5 |
Member of these Panels
| LOINC | Long Common Name |
|---|---|
| 112441-1 | Adverse Childhood Experience Questionnaire for Adults [ACE Questionnaire for Adults] |