| 1 Has the abuser physically injured you in the past? |
Yes |
N o |
| 2 Has the abuser physically injured you in this incident? |
Yes |
N o |
| 3 Has the severity or frequency of violence increased in the last two weeks? |
Yes |
N o |
| 4 Has the abuser ever physically injured your children in the past? |
Yes |
N o |
| 5 Has the abuser physically injured your children now? |
Yes |
N o |
| 6 Has the abuser ever sexually abused any of your children? |
Yes |
N o |
| 7 Has he ever threatened to kill you in the past? |
Yes |
N o |
| 8 Is the abuser threatening to kill you now? |
Yes |
N o |
| 9 Is the abuser threatening to commit suicide now? |
Yes |
N o |
| 10 Have you attempted to commit suicide or kill your children in the past? |
Yes |
N o |
| 11 If “yes” to question 10, was it within the last six months/6 months – 1 year / 1 year – 2 years / more than 2 years |
Yes |
N o |
| 12 Are you planning to commit suicide and/or kill your children now? |
Yes |
N o |
| 13 Has there been severe sexual violence in the last two weeks?(e.g. forced sex or anything bizarre about the sexual activities, if so make a note) |
Yes |
N o |
| 14 Has there been a substantial increase in the consumption
of alcohol by the abuser in the last one-month? |
Yes |
N o |
| 15 Has there been a substantial increase in the consumption
of drugs by the abuser in the last one-month? |
Yes |
N o |