Before age 18:

1. Did a parent or other adult in the household often or very often:
   
   • Swear at you
   • insult you
   • put you down
   • humiliate you, OR
   • act in a way that made you afraid that you might be physically hurt?
   yes no


2. Did a parent or other adult in your household:
   • often push, grab, slap, or throw something at you OR
   • ever hit you so hard that you had marks or were injured?
   yes no


3. Did an adult or person 5+ years older than you ever:
   • fondle you or have you touch their body in a sexual way OR
   • attempt or have any form of intercourse with you?
   yes no


4. Did you often feel that:
   • no one in your family loved you or thought you were important or special OR
   • your family didn’t look out for, support or feel close to each other?
   yes no


5. Did you often or very often feel that:
   • you didn’t have enough to eat, had to wear dirty clothes and had no one to protect you OR
   • your parents were too drunk or high to take care of you or take you to the doctor if needed?
   yes no


6. Were your parents ever separated or divorced?
   yes no


7. Was your mother or stepmother:
   • often pushed, grabbed, slapped, or had something thrown at her OR
   • often kicked, bitten, hit with a fist, or hit with something hard OR
   • ever repeatedly hit over several minutes or threatened with a gun or knife?
   yes no


8. Did you live with anyone who:
   • was a problem drinker or alcoholic OR
   • used street drugs?
   yes no


9. Was a household member depressed or mentally ill OR did a household member attempt suicide?
   yes no


10. Did a household member go to prison?
    yes no