The following questions ask about difficult events you may have experienced in your lifetime.
1. As a child, did a parent or adult in your home ever hit, beat, kick, or physically hurt you in any way? Do not include spanking.
- Yes
- No
2. As a child, did your parents or adults in your home ever slap, hit, beat, kick, or physically hurt each other?
- Yes
- No
3. As a child, did an adult or anyone at least 5 years older than you ever touch you sexually, try to make you touch them sexually, or force you to have sex?
- Yes
- No
4. As a child, were your parents separated or divorced?
- Yes
- No
5. As a child, was either one of your parents absent from your life for a long period of time?
- Yes
- No
6. As an adult, have you been hit, beat, kicked, or physically hurt by a partner or spouse?
- Yes
- No
7. As an adult, has anyone ever forced you to have sexual activities?
- Yes
- No
8. In your lifetime, has a parent/caregiver or partner/spouse of yours ever been a problem drinker or alcoholic?
- Yes
- No
9. In your lifetime, has a parent/caregiver or partner/spouse of yours ever used illegal drugs or abused prescription medications?
- Yes
- No
10. In your lifetime, has a parent/caregiver or partner/spouse of yours ever been depressed, mentally ill, or suicidal?
- Yes
- No
11. In your lifetime, has a parent/caregiver or partner/spouse of yours ever been to prison or jail?
- Yes
- No
12. In your lifetime, have you ever been the victim of a violent crime* such as armed robbery or physical assault?
- Yes
- No
*Violent crime refers to a violent act by someone other than a spouse, partner or household family member. Do not include sexual violence.
13. As a child, how often did a parent/caregiver ever swear at you, insult you, or put you down?
- Never
- Rarely
- Sometimes
- Often
- Very Often
14. As an adult, how often has a spouse/partner ever screamed at you or threatened you with harm?
- Never
- Rarely
- Sometimes
- Often
- Very Often
15. In your lifetime, how often have you felt that you have been discriminated against or treated unfairly because of race, gender or other personal characteristics?
- Never
- Rarely
- Sometimes
- Often
- Very Often
16. In your lifetime, how often have you been hungry because your family could not afford food?
- Never
- Rarely
- Sometimes
- Often
- Very Often
17. In your lifetime, how often have you been homeless*?
- Never
- Rarely
- Sometimes
- Often
- Very Often
*Homeless means having to stay somewhere like a transitional housing program, a shelter, a hotel/motel paid by voucher, someone else’s home, a car or other vehicle, an abandoned building, anywhere outside, or anywhere else not meant for people to live.
Supplemental Questions
18. As a child, were you often bullied or severely teased by other children or adolescents?
- Yes
- No
19. In your lifetime, have you ever seen someone die suddenly or get badly hurt or killed?
- Yes
- No
20. In your lifetime, has a close friend or family member died suddenly?
- Yes
- No
21. In your lifetime, have you experienced a really bad car, boat, train, or airplane accident?
- Yes
- No
22. In your lifetime, have you been in a hurricane, flood, earthquake, tornado, or fire?
- Yes
- No
23. During or after your child’s birth, did you feel that your life or your baby’s life was threatened?
- Yes
- No
24. Around the time of your child’s birth, did you or your baby experience an actual injury or threat of serious injury?
- Yes
- No
For further information about this measure, contact: Dr. Joshua Mersky (mersky@uwm.edu) or Dr. James Topitzes (topitzes@uwm.edu), University of Wisconsin-Milwaukee.