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Questionnaire
The
following questions have been designed for victims or anyone involved with
a victim to identify abuse by actions of abusers and responses of victims.
The categories have been broken down into three categories:
Children also suffer
from the impact of family violence, often silently blame themselves and
carry guilt due to believing they are at fault. They often respond by
suffering physical ailments as well as emotional outbursts. (See impact on
children).
If you answer 'yes' to
any more than two of these questions, you may be in an abusive or
controlling relationship. The more questions that have a 'yes' response,
indicate how abusive the relationship is and may be used as a 'risk
assessment' for victims and / or concerned relatives and friends.
Have you ever:
Been pushed or shoved?
Grabbed?
Slapped or bitten?
Kicked or choked?
Hit or punched?
Burned?
Shaken?
Choked?
Objects been thrown at you?
Thrown downstairs?
Had your hair pulled?
Deprived of sleep, heat or food?
Assaulted with a weapon? e.g.,
guns, knives, whips, tire irons, cars, bats, broken bottles, cigarettes, hot beverages,
etc..
Physically kept from leaving the home
for events / or leaving the relationship?
Locked out of your home and have to
beg to enter?
Abandoned in dangerous or isolated
areas?
Refused you help when you are ill,
injured or pregnant?
Hit while you were pregnant?
Subjected you to reckless driving?
Has your intimate partner ever:
Feelings been ignored?
Embarrassed or ridiculed women as a
group?
Ridiculed or insulted because of your
values, beliefs, religion, race, heritage or class?
Withheld approval, appreciation or
affection as punishment
Continually criticized you, called you
names e.g. stupid, ugly, worthless, fat, idiot, etc.
Undermined your education or refused
you to allow you to take additional courses?
Shouted at you to intimidate,
humiliate or frighten you?
Insulted your family members, drove
them away?
Demanded you where the clothes he had
chosen and/or destroyed your favourite dress?
Prevented you from being with family,
friends, and co-workers?
Humiliated you in private or public
place?
Refused to socialize with you or acted
in a manner that embarrassed you in front of friends and family?
Took you car keys, money, and credit
cards as a way of punishing you?
Controlled you financially and
demanded your assets and wages be turned over to him?
Failed or denied you joint ownership
of property, banks accounts etc.?
Deliberately hidden your personal
effects and denied knowledge of their whereabouts?
Regularly threatened to leave you, or
make you go away?
Belittled your accomplishments?
Threatened to hurt you or your family
or children?
Punished or deprived the children if
angry at you?
Threatened to kidnap the children if
you left him, or return them to his country of origin?
Threatened, abused or killed the
family pet?
Bragged about his affairs or compared
to you his lovers?
Harassed you about imaginary affairs?
e.g. boss or co-worker?
Manipulated you with lies and
contradictions?
Subjected you to rapid fire questions
and demanded immediate responses?
Threatened to tell family and friend
of intimate secrets?
Made you dress provocatively to
entertain him?
Forced you to perform sexual acts
against your will?
Insisted on unwanted or uncomfortable
touching?
Referred to you or treated you as a
prostitute?
Forced sex after beating?
Forced sex while you were sick,
pregnant, or immediately after childbirth?
Forced sex with objects or weapons or
sadistic sexual acts?
Demanded numerous sex within a 24 hour
period?
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