Part 1:

Informed Consent
This is Abdul Jabbar student of Advanced Diploma in Clinical Psychology (ADCP) at
Bahauddin Zakariya University Multan. I am conducting this research as a part of degree
completion under the supervision of Dr. Sara Mahmood. The title of my research is "Exploring
the Impact of Adverse Childhood Experiences on the development of Addictive Behaviors
among individuals with Co morbidity".
This questionnaire will take maximum 10 minutes of your time. The participation in this research
will be voluntary and you can withdraw it at any time. It is to assure you that the confidentiality
will be maintained and data collected will be used for research purpose only. During filling in
this if you feel any sought of inconvenience please consult your doctor. If you have any further
question related to this research please contact the details given below. THANK YOU.
jaankakar2006@gmail.com

Part 2:
Age ------------ Education----------------
Socioeconomic Status ------------------------

Part 3:
From the list below, please place a checkmark next to each ACE category that you experienced
prior to your 18th birthday. Then, please add up the number of categories of ACEs you
experienced and put the total number at the bottom.
1= Not Much
2= Some
3= A lot

No. Statements 1 2 3
1 Did you feel that you didn’t have enough to eat, had to wear dirty clothes, or had
no one to protect or take care of you?
2 Did you lose a parent through divorce, abandonment, death, or other reason?
3 Did you live with anyone who was depressed, mentally ill or attempted suicide?
4 Did you live with anyone 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 each other?
6 Did you live with anyone who went to jail or prison?
7 Did a parent or adult in your home ever swear at you, insult you, or put you
down?
8 Did a parent or adult in your home ever hit, beat, kick, or physically hurt you in
any way?
9 Did you feel that no one in your family loved you or thought you were special?
10 Did you experience unwanted sexual contact (such as fondling or
oral/anal/vaginal intercourse/penetration)?

When the words “drug abuse” is used, they mean the use of prescribed or over‐the‐counter
medications/drugs in excess of the directions and any non‐medical use of drugs. The various
classes of drugs may include: cannabis (e.g., marijuana, hash), solvents, tranquilizers (e.g.,
Valium), barbiturates, cocaine, and stimulants (e.g., speed), hallucinogens (e.g., LSD) or
narcotics (e.g., heroin). Remember that the questions do not include alcohol or tobacco. If you
have difficulty with a statement, then choose the response that is mostly right. You may choose
to answer or not answer any of the questions in this section.
No. These questions refer to the past 12 months. No Yes
1 Have you used drugs other than those required for medical reasons? 0 1
2 Do you abuse more than one drug at a time? 0 1
3 Are you always able to stop using drugs when you want to? (If never use drugs,
0 1
answer “Yes.”
4 Have you had "blackouts" or "flashbacks" as a result of drug use? 0 1
5 Do you ever feel bad or guilty about your drug use? If never use drugs, choose
0 1
“No.”
6 Does your spouse (or parents) ever complain about your involvement with
0 1
drugs?
7 Have you neglected your family because of your use of drugs? 0 1
8 Have you engaged in illegal activities in order to obtain drugs? 0 1
9 Have you ever experienced withdrawal symptoms (felt sick) when you stopped
0 1
taking drugs?
10 Have you had medical problems as a result of your drug use (e.g., memory loss,
0 1
hepatitis, convulsions, bleeding, etc.)?

Please read each statement and circle a number 0, 1, 2 or 3 which indicates how much the
statement applied to you over the past week. There is no right or wrong answers. Do not spend
too much time on any statement.
The rating scale is as follows:
0= Did not apply to me at all (Never)
1= Applied to me to some degree, or some of the time (Sometimes)
2= Applied to me to a considerable degree or a good part of time (Often)
3= Applied to me very much or most of the time (Almost Always)
No. Statements 0 1 2 3
1 I found it hard to wind down
2 I was aware of dryness of my mouth
3 I couldn’t seem to experience any positive feeling at all
4 I experienced breathing difficulty (e.g. excessively rapid breathing,
breathlessness in the absence of physical exertion)
5 I found it difficult to work up the initiative to do things
6 I tended to over-react to situations
7 I experienced trembling (e.g. in the hands)
8 I felt that I was using a lot of nervous energy
9 I was worried about situations in which I might panic and make a fool of
myself
10 I felt that I had nothing to look forward to
11 I found myself getting agitated
12 I found it difficult to relax
13 I felt down-hearted and blue
14 I was intolerant of anything that kept me from getting on with what I was
doing
15 I felt I was close to panic
16 I was unable to become enthusiastic about anything
17 I felt I wasn’t worth much as a person
18 I felt that I was rather touchy
19 I was aware of the action of my heart in the absence of physical exertion (e.g.
sense of heart rate increase, heart missing a beat)
20 I felt scared without any good reason
21 I couldn’t seem to experience any positive feeling at all

Thanks for your participation