Items:

Circle a number of each of the items listed below to show your closest estimate of how often it happened in your relationship with your partner or former partner during the six months prior (the time frame for reporting abuse can be modified to fit the needs of research setting).

1. Called you name andor criticized you
2. Tried to keep you from doing something you wanted to do (example: going out with friends, going to meetings)
3. Gave you angry stares or looks
4. Prevented you from having money for your own use
5. Ended a discussion with you and made the decision himself
6. Threatened to hit or throw something at you
7. Pushed, grabbed, or shoved you
8. Put down your family and friends
9. Accused you of paying too much attention to someone or something else
10. Put you on an allowance
11. Used your children to threaten you (example: told you that you would lose custody, said he would leave town with the children)
12. Became very upset with you because dinner, housework, or laundry was not ready when he wanted it or done the way it should be
13. Said things to scare you (examples: told you something “bad” would happen, threatened to commit suicide)
14. Slapped, hit, or punched you
15. Made you do something humiliating or degrading (example: begging for forgiveness, having to ask his permission to use the car or do something)
16. Checked up on you (examples: listened to your phone calls, checked the mileage on your car, called you repeatedly at work)
17. Drove recklessly when you were in the car
18. Pressured you to have sex in a way that you didn’t like or want
19. Refused to do housework or childcare
20. Threatened you with a knife, gun, or other weapon
21. Spanked you
22. Told you that you were a bad parent
23. Stopped you or tried to stop you from going to work or school
24. Threw, hit, kicked, or smashed something
25. Kicked you
26. Physically forced you to have sex
27. Threw you around
28. Physically attacked the sexual parts of your body
29. Choked or strangled you
30. Used a knife, gun, or other weapon against you

Response Options:
Never - 1
Rarely - 2
Occasionally - 3
Frequently - 4
Very Frequently - 5