1/8
1
Has the other person carried out dangerous acts to harm or threaten you
(e.g., using a knife, gun, bottle, metal objects, club; sulfuric acid; gasoline; or ramming you with a car or motorcycle…)?
2/8
2
Has the other person used violence that interfered with your breathing?
(e.g., strangling/choking, smothering your face, pushing your head under water, turning on gas, or other: ____ )
3/8
3
Has the other person physically assaulted you outside the residence
(e.g., in public, at someone else’s home, or in places where others could witness it)?
4/8
4
Has the other person used physical violence against non-family members
(e.g., friends, neighbors, coworkers, strangers)?
5/8
5
Has the other person taken you away or confined you without your consent?
6/8
6
Has the other person threatened to kill you?
7/8
7
Do you believe the other person could kill you?
8/8
8
In the past year, has the violence against you become more severe or more frequent?