Pediatric ACEs and Related Life Events Screener (PEARLS)
TEEN (Self-Report)- To be completed by: Patient
At any point in time since you were born, ha
ve you 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 (Self Report) - Deidentified
1. Have you ever lived with a parent/caregiver who went to jail/prison?
2. Have you ever felt unsupported, unloved and/or unprotected?
3. Have you 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 you down?
5. Has your biological parent or any caregiver ever had, or currently has a problem with too
much alcohol, street drugs or prescription medications use?
6. Have you ever lacked appropriate care by any caregiver?
(for example, not being protected from unsafe situations, or not being cared for when sick
or injured even when the resources were available)
7. Have you ever seen or heard a parent/caregiver being screamed at, sworn at, insulted or
humiliated by another adult?
Or have you 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 you?
Or has any adult in the household ever hit you so hard that you had marks or were injured?
Or has any adult in the household ever threatened you or acted in a way that made you
afraid that you might be hurt?
This tool was created in partnership with UCSF School of Medicine.
Have you ever experienced sexual abuse?
(for example, has anyone touched you or asked you to touch that person in a way that was
unwanted, or made you feel uncomfortable, or anyone ever attempted or actually had oral,
anal, or vaginal sex with you)
10. Have there ever been signicant changes in the relationship status of your caregiver(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?: