Psychiatrist Template

Adverse Childhood Experiences (ACEs) Assessment

A professional Psychiatrist template for healthcare professionals.

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Specialty

Psychiatrist

Used

74 times

Type

Note

Last edited

5/26/2025

Created by

Stella Lee

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About this template

The Adverse Childhood Experiences (ACEs) Assessment template is a vital tool for obstetricians and gynaecologists to evaluate the impact of early traumatic experiences on a patient's health. This template helps clinicians systematically assess ten key areas of childhood adversity, such as family dysfunction and abuse, to calculate an ACE score. Understanding these experiences is crucial for providing comprehensive care, as they can significantly influence a patient's physical and mental health. The template is designed for use with Heidi, ensuring efficient and accurate documentation during patient consultations.

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Client name: Sarah Johnson 1. Did you often feel that you didn’t have enough to eat, had to wear dirty clothes, or had no one to protect or care for you? [ ] 2. Did you lose a parent through divorce, abandonment, death, or another reason? [X] 3. Did you live with someone who was depressed, mentally ill, or who attempted suicide? [X] 4. Did you live with someone who had a problem with drinking or using drugs, including prescription drugs? [ ] 5. Did your parents or adults in your home ever hit, punch, beat, or threaten to harm one another? [X] 6. Did you live with someone who went to jail or prison? [ ] 7. Did a parent or adult in your home frequently swear at you, insult you, or belittle you? [X] 8. Did a parent or adult in your home ever hit, beat, kick, or physically harm you? [ ] 9. Did you often feel that no one in your family loved you or thought you were special? [X] 10. Did you experience any unwanted sexual contact (e.g., fondling, or oral/anal/vaginal intercourse/penetration)? [ ] Total ACE Score: 5 Follow-Up Questions: - Do you feel that these experiences have impacted your overall health? - Not Much [ ] - Some [X] - A Lot [ ]