Has the physical violence increased in severity or frequency over the past year?

Does he own a gun?

Have you left him after living together during the past year?

Have you NEVER lived with him?

Is he unemployed?

Has he ever used a weapon against you or threatened you with a lethal weapon?

If yes to the previous question, was the weapon a gun?

Does he threaten to kill you?

Has he avoided being arrested for domestic violence?

Do you have a child that is not his?

Has he ever forced you to have sex when you did not wish to do so?

Does he ever try to choke/strangle you or cut off your breathing?

If yes to the previous question, has he done it more than once, or did it make you pass out or blackout or make you dizzy?

Does he use illegal drugs? By drugs, I mean “uppers” or amphetamines, “meth”, speed, angel dust, cocaine, “crack”, street drugs or mixtures.

Is he an alcoholic or problem drinker?

Does he control most or all of your daily activities? For instance, does he tell you who you can be friends with, when you can see your family, how much money you can use, or when you can take the car?

In reference to the previous question, do you let him control most or all of your activities?

Is he violently and constantly jealous of you? (For instance, does he say: “If I can’t have you, no one can.”)

Have you ever been beaten by him while you were pregnant?

Have you ever been pregnant by him?

Has he ever threatened or tried to commit suicide?

Does he threaten to harm your children?

Do you believe he is capable of killing you?

Does he follow or spy on you, leave threatening notes or messages, destroy your property, or call you when you don’t want him to?

Have you ever threatened or tried to commit suicide?

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