Fillable Pediatric AC Es And Related Life Events Screener (PEARLS) (ACEs Aware)

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Pediatric AC Es And Related Life Events Screener (PEARLS) (ACEs Aware)

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Pediatric ACEs and Related Life Events Screener
CHILD
Many families experience stressful life events.
Over time these experiences can affect your
child’s health and wellbeing. We would like to ask
you questions about your child so we can help
them be as healthy as possible.
Pediatric ACEs and Related Life Events Screener (PEARLS)
CHILD - To be completed by: Caregiver
At any point in time since your child was born, has your child seen or been present when the
following experiences happened? Please include past and present experiences.
Please note, some questions have more than one part separated by “OR.” If any part of the
question is answered “Yes,” then the answer to the entire question is “Yes.”
PART 1:
Child (Parent/Caregiver Report) – Deidentied
1. Has your child ever lived with a parent/caregiver who went to jail/prison?
This tool was created in partnership with UCSF School of Medicine.
2. Do you think your child ever felt unsupported, unloved and/or unprotected?
3. Has your child ever lived with a parent/caregiver who had mental health issues?
(for example, depression, schizophrenia, bipolar disorder, PTSD, or an anxiety disorder)
4. Has a parent/caregiver ever insulted, humiliated, or put down your child?
5. Has the child’s biological parent or any caregiver ever had, or currently has a problem with
too much alcohol, street drugs or prescription medications use?
6. Has your child ever lacked appropriate care by any caregiver?
(for example, not being protected from unsafe situations, or not cared for when sick or
injured even when the resources were available)
7. Has your child ever seen or heard a parent/caregiver being screamed at, sworn at, insulted
or humiliated by another adult?
Or has your child ever seen or heard a parent/caregiver being slapped, kicked, punched
beaten up or hurt with a weapon?
8. Has any adult in the household often or very often pushed, grabbed, slapped or thrown
something at your child?
Or has any adult in the household ever hit your child so hard that your child had marks or
was injured?
Or has any adult in the household ever threatened your child or acted in a way that made
your child afraid that they might be hurt?
9. Has your child ever experienced sexual abuse?
(for example, anyone touched your child or asked your child to touch that person in a way
that was unwanted, or made your child feel uncomfortable, or anyone ever attempted or
actually had oral, anal, or vaginal sex with your child)
10. Have there ever been signicant changes in the relationship status of the child’s
caregiver(s)?
(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in
or out)
Please continue to the other side for the rest of questionnaire
Add up the “yes” answers for this rst section:
PART 2:
Please check “Yes” where apply.
√
Child (Parent/Caregiver Report) – Identified
This tool was created in partnership with UCSF School of Medicine.
1. Has your child ever seen, heard, or been a victim of violence in your neighborhood,
community or school?
(for example, targeted bullying, assault or other violent actions, war or terrorism)
2. Has your child experienced discrimination?
(for example, being hassled or made to feel inferior or excluded because of their race,
ethnicity, gender identity, sexual orientation, religion, learning differences, or disabilities)
3. Has your child ever had problems with housing?
(for example, being homeless, not having a stable place to live, moved more than two
times in a six-month period, faced eviction or foreclosure, or had to live with multiple
families or family members)
4. Have you ever worried that your child did not have enough food to eat or that the food for
your child would run out before you could buy more?
5. Has your child ever been separated from their parent or caregiver due to foster care, or
immigration?
6. Has your child ever lived with a parent/caregiver who had a serious physical illness or
disability?
7. Has your child ever lived with a parent or caregiver who died?
Add up the “yes” answers for the second section:
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Pediatric AC Es And Related Life Events Screener (PEARLS) (ACEs Aware)

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Completed 19 May 2021

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