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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TEEN (Self-Report)
Many families experience stressful life events.
Over time these experiences can affect yo
ur
health and wellbeing. We would like to ask you
questions so we can help you
be as healthy as
possible.
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.”
PART 1:
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?
9.
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 signicant 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
or out)
Please continue to the other side for
the rest of questionnaire
How many “Yes” did you answer in Part 1?:
PART 2: Please check “Yes” where apply.
√
Teen (Self Report) - IdentiedThis tool was created in partnership with UCSF School of Medicine.
1. Have you 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. Have you 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. Have you 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 you did not have enough food to eat or that food would run out
before you or your parent/caregiver could buy more?
5. Have you ever been separated from your parent or caregiver due to foster care, or
immigration?
6.
Have you ever lived with a parent/caregiver who had a serious physical illness or
disability?
7.
Have you ever lived with a parent or caregiver who died?
8.
Have you ever been detained, arrested or incarcerated?
9. Have you ever experienced verbal or physical abuse or threats from a romantic partners?
(for example, a boyfriend or girlfriend)
How many “Yes” did you answer in Part 2?:
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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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