Pediatric ACEs and Related Life Events Screener (PEARLS)
TEEN (Parent/Caregiver Report) - 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.”
Teen (Parent/Caregiver Report) - Deidentified
1. Has your child ever lived with a parent/caregiver who went to jail/prison?
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?
This tool was created in partnership with UCSF School of Medicine.
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
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 signicant changes in the relationship status of the child’s
(for example, a parent/caregiver got a divorce or separated, or a romantic partner moved in
Please continue to the other side for the rest of questionnaire
How many “Yes” did you answer in Part 1?: