Appendix H. Registratieformulier signalen van FHG bij volwassen

Registratieformulier

 

The Partner Abuse Interview (49)

"Many people, at one time or another, get physica! with their partner when they're angry. For example, some peopie threaten to hurt their partners, some push or shove, and some slap or hit. I’m going to ask you about a variety of common behaviors, and l’d like you to teil me if your partner did these during the past year."

For each behavior answered “no," put a “zero” in the appropriate box and ask if the patiënt was bruised or injured in any other way.

If the answer is "yes," code "1" for no injury, "2" for possible injury, and "3" for injury.

 

Has

 your partner...

Yes/No

Injury Codes

1.

Thrown something at you

( )

1 2 3

2.

Pushed, grabbed, or shoved you

( )

1 2 3

3.

Slapped you

( )

1 2 3

4.

Kicked, bit, hit you with a fist

( )

1 2 3

5.

Hit or tried to hit you with an object

( )

1 2 3

6.

Beat you up

( )

1 2 3

7.

Threatened you with a gun or knife

( )

1 2 3

8.

üsed a gun or knife

( )

1 2 3

9.

Forced you to have sex when you didn’t want to

( )

1 2 3

10.

Other

( )

1 2 3
 

 

Ask the following question if the answer to any of the above questions is anything other than "zero.”

11. "Some people are afraid that their partners will physically hurt them if they argue with their partners or do something their partners don't like. How much would you say you are afraid of this happening to you?"

( ) Not at all (1)

( ) A little (2)

( ) Quite a bit/Very afraid (3)

 

Screening Questions for Domestic Violente (50)

Have any of the following ever happened to you? Answer yes or no.

  1. Has your male partner (husband, boyfriend) hit, slapped, kicked, orotherwise physically hurt you?
  2. If you are pregnant, has your male partner hit, slapped, kicked, pushed, or otherwise physically hurt you since you've been pregnant?
  3. Has your male partner forced you to have sexual activities?
  4. Are you afraid of your male partner?

A "yes" response to any question is considered positive for partner violence.

 

Domestic Abuse Assessment Questionnaire (51)

Answer "yes" or "no."

  1. Have you ever been emotionally or physically abused by your partner or someone important to you?
  2. Within the last year, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
  3. Since your pregnancy began, have you been hit, slapped, kicked, or otherwise physically hurt by someone?
  4. Within the last year, has anyone forced you to have sexual activities?
  5. Are you afraid of your partner or anyone else?

A "yes" response on any question is considered positive for partner violence.

 

Woman Abuse Screening Tool (WAST) (57)

1. In general, how would you describe your relationship?

a lot of tension          some tension          no tension

2. Do you and your partner work out arguments with ...

great difficulty          some difficulty          no difficulty

3. Do arguments ever result in you feeling put down or bad about yourself?

often          sometimes          never

4. Do arguments ever result in hitting, kicking, or pushing?

often          sometimes          never

5. Do you ever feel frightened by what your partner says or does?

often          sometimes          never

6. Has your partner ever abused you physically?

often          sometimes          never

7. Has your partner ever abused you emotionally?

often          sometimes          never

8. Has your partner ever abused you sexually?

often          sometimes          never

To score this instrument, the responses are assigned a number. For the first question, “a lot of tension" gets a score of 1 and the other 2 get a 0. For the second question, "great difficulty" gets a score of 1 and the other 2 get 0. For the remaining questions, "often" gets a score of 1, "sometimes" gets a score of 2, and "never" gets a score of 3.

 

Domestic Violence Screening Tool (58)

  1. Have you ever been threatened, hit, punched, slapped, or injured by a husband, boyfriend, or significant other you had at any point in the past?
  2. Have you ever been hurt or frightened so badly by a husband, boyfriend, or significant other that you were in fear for your life?
  3. Have you been hit, punched, slapped, or injured by a husband, boyfriend, or significant other within the last month?
  4. Are you currently involved in a close relationship with a husband, boyfriend, or significant other?
  5. Are you here today for injuries received from your husband, boyfriend, or significant other?
  6. Do you often feel stressed due to fear of threats or violent behavior from your current husband, boyfriend, or significant other?
  7. Has your current husband, boyfriend, or significant other ever hit, punched, slapped, or injured you?
  8. Do you think it is iikely that your husband, boyfriend, or significant other will hit, slap, punch, kick, or otherwise hurt you in the future?
  9. Do you think you will be safe if you go back home to your husband, boyfriend, or significant other at this time?

A "yes” response to any question is considered positive for partner violence.