Check Yes or No to the best of your ability for the following...

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Physical Abuse

1. Has your partner ever pushed, slapped, kicked, or otherwise physically hurt you? (Y/N)

2. Has your partner ever choked, strangled, or suffocated you or attempted to? (Y/N)

3. Has your partner ever physically hurt you badly enough to leave a bruise, cut, burn, or other mark? (Y/N)

4. Has your partner ever attacked you with a weapon? (A stick, knife, or other object.) (Y/N)

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Emotional Abuse

5. Do you often feel anxious when your partner is nearby? (Y/N)

6. Do you carefully watch your behaviour to avoid making your partner angry? (Y/N)

7. Has your partner ever intentionally destroyed something that belongs to you? (Y/N)

8. Does your partner embarrass you or shame you in front of others? (Y/N)

9. Does your partner consistently accuse you of cheating or having affairs? (Y/N)

10. Does your partner blame you for their anger or behaviour? (Y/N)

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Sexual Abuse

11. Does your partner force you to have sex by persuading, threatening, or blackmailing you? (Y/N)

12. Does your partner physically force you to have sex? (Y/N)

13. Does your partner refuse to allow birth control or STD protection? (Y/N)

14. Does your partner force you to perform sexual acts you are not comfortable with? (Y/N)

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Controlling Behaviours

15. Has your partner forced you to quit your job or education? (Y/N)

16. Has your partner ever tried to stop you from seeing your friends or family? (Y/N)

17. Do you feel embarrassed to share about how your partner treats you with your family and friends? (Y/N)

18. Does your partner say that if you leave, they will harm themselves or you? (Y/N)

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