Items:

Psychological violence

1. Has he insulted you or made you feel bad about yourself?
2. Has he belittled or humiliated you in front of other people?
3. Has he done things to scare or intimidate you on purpose?
4. Has he threatened to hurt you or someone you care about?

Physical violence

5. Has he slapped you or thrown something at you that could hurt you?
6. Has he pushed or shoved you?
7. Has he hit you with his fist or with something else that could hurt you?
8. Has he kicked you, dragged you or beaten you up?
9. Has he choked or burnt you on purpose?
10. Has he threatened to use or actually used a gun, knife or other weapon against you?

Sexual violence

11. Has he physically forced you to have sexual intercourse when you didn’t want to?
12. Did you ever have sexual intercourse when you didn’t want because you were afraid of what he might do?
13. Has he forced you to do something sexual that you found degrading or humiliating?

Response Options:
Yes
No