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Domestic Violence Risk Assessment

 

This questionnaire gives a sense of the likelihood of experiencing, or already being the victim of, domestic violence.

Has your partner threatened you physically?
Yes
No
Has your partner struck you, pushed you, grabbed you roughly, thrown you, or choked you? Yes No
Have you sustained physical injury from your partner? Yes No
Does your partner blame you for any injury that you might have sustained from him or her? Yes No
Has your partner pressured you into any sexual activity that made you feel uncomfortable or degraded? Yes No
Has your partner forced you to have sex? Yes No
Has your partner ever raped or attempted to rape you? Yes No

Does your partner yell at you or call you names?

 Yes No
Does your partner embarrass you in front of others? Yes No
Do you feel belittled regularly by your partner? Yes No

Does your relationship otherwise feel conflicted or unstable?

 Yes No
Were you or your partner the victim of, or otherwise experience, any pattern of abuse as a child or young adult? Yes No
Does your partner seem to have low self-esteem? Yes No
Does your partner have a rigid belief in male/female roles? Yes No

Is your partner destructive to your possessions or your physical environment?

 Yes No

Does your partner become aggressive when drunk or using drugs?

 Yes No

Does your partner use drunkenness or drug use as an excuse for behaving in an aggressive manner towards you?

 Yes No
Does your partner blame you when he or she behaves poorly? Yes No

Do you find yourself denying the nature of aggressive incidents after they occur?

 Yes No
Do you have a habit of finding, or looking for, a way to blame yourself for your partner’s behavior? Yes No
Does your partner try to limit your relationship with family and friends? Yes No
Are you isolated from family and friends? Yes No
Are you or disabled? Yes No
Do you feel that your partner is overly controlling of your time, attention, actions, words, activities, or whereabouts? Yes No
Does your partner sometimes seem obsessed with you or extremely jealous of you? Yes No
Does your partner seem, hostile, angry, or furious often? Yes No
Has your partner previously been involved with incidents of violence? Yes No
Does your partner’s aggressive behavior seem to occur in cycles? Yes No
Has your partner every threatened to hurt himself or herself to punish you? Yes No
Is your partner hurtful toward – or ever threaten to hurt – children, pets, or others? Yes No
Does your partner make you overly or directly dependent for all money? Yes No
Do you worry about what your partner would do if you broke up with him or her? Yes No
Have you ever felt stalked by your partner? Yes No
Have you previously been in an abusive relationship? Yes No
Do you have plans to end this relationship? Yes No
Is your partner aware of your plans to end this relationship? Yes No
Do you experience physical or mental affects such as anxiety, depression, fatigue, or stomach or other gastrointestinal pain or problems that you feel are might be a result of stress related to your partner’s behavior toward you? Yes No


The more often you answered “Yes” to the above questions, the greater the chance that you will become, or that you already are, the victim of domestic violence.  If you answered “Yes” to questions above, consider discussing domestic violence with one of our Women’s Center healthcare providers.

Print this page and bring it with you, filled out, to your appointment.

  

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