ONE: Did a parent or other adult in the household often or very often push, grab, slap or throw something at you? Or ever hit you so hard that you had marks or were injured?
TWO: Did a parent or other adult in the household often or very often swear at you, insult you, put you down or humiliate you? Or act in a way that made you afraid that you might be physically hurt?
THREE: Did an adult or person at least five years older than you ever touch or fondle you or have you touch their body in a sexual way? Or attempt, or actually have, oral, anal or vaginal intercourse with you?
FOUR: Did you often or very often feel that no one in your family loved you or thought you were important or special, or that your family didn’t look out for each other, feel close to each other or support each other?
FIVE: Did you often or very often feel that you didn’t have enough to eat, had to wear dirty clothes or 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 you needed to go?
SIX: Did you live with anyone who was a problem drinker or alcoholic? Or who used street drugs?
SEVEN: Was your parent or stepparent often or very often pushed, grabbed, slapped or hit by a thrown object? Or sometimes, often, or very often, kicked, bitten, hit with a fist or hit with something hard? Or ever repeatedly hit for at least a few minutes or threatened with a gun or knife?
EIGHT: Was a household member depressed or mentally ill? Or did a household member attempt suicide?
NINE: Were your parents separated or divorced?
TEN: Did a household member go to prison?