Items:

Severe Combined Abuse

1. Held me down and cut my pubic hair
2. Prostituted me
3. Forced me to have sex with other partners
4. Tortured or killed pets to hurt me
5. Kept me from medical care
6. Threatened me with a knife or gun
7. Used a knife or gun or other weapon
8. Locked me in the bedroom
9. Put foreign objects in my vagina
10. Disabled my car
11. Refused to let me work outside my home
12. Raped me
13. Tried to rape me
14. Choked me
15. Stole my possessions
16. Forced me to do unwanted sex acts
17. Took my wallet and left me stranded

Emotional Abuse

18. Tried to turn my family, friends, and children against me
19. Tried to make me think I was crazy
20. Told me that I was crazy
21. Tried to convince family, friends, and children that I was crazy
22. Punisheddeprived children when angry at me
23. Became upset if dinnerhousework wasn’t done when they thought it should be
24. Told me that I wasn’t good enough
25. Tried to keep me from seeing or talking to my family
26. Told me that I was stupid

Physical Abuse

27. Shook me
28. Hit or tried to hit me with something
29. Pushed, grabbed or shoved me
30. Kicked me, bit me, or hit with a fist
31. Slapped me
32. Threw me
33. Beat me up
34. Told me that I was a horrible partner
35. Threatened to hit me or throw something at me
36. Blamed me for the violence

Harassment

37. Harassed me over the telephone
38. Harassed me at work
39. Followed me
40. Took my car keys and left me stranded
41. Hung around outside my house
42. Restricted my use of the telephone
43. Did not allow me to socialize with my female friends

Response Options:
Daily, once per week, once per month, several times, and only once