| Checklist of Behaviors
Please check all behaviors that apply. Has your partner/date ever:
Physical Abuse:
___ Pushed or shoved you?
___ held you to keep you from leaving?
___ hit, slapped or kicked you?
___ thrown things at you?
___ bit or scratched you?
___ locked you in a room or closet?
___ abandoned you in dangerous places?
___ refused you help when you were sick or injured?
___ drove recklessly when you were with her?
___ pushed you down stairs?
___ choked you?
___ deprived you of sleep or food?
___ stabbed you?
___ shot at you?
Sexual Abuse:
___ assumed you would have sex with anyone available?
___ minimized the importance of your feelings about sex?
___ insisted you dress in a more sexual way than you wanted?
___ criticized you sexually?
___ insisted on unwanted and uncomfortable touching?
___ withheld sex and affection?
___ called you sexual names like "frigid," "slut"?
___ publicly showed an interest in other women?
___ had affairs with other women after agreeing to a monogamous
relationship?
___ forced you to have sex when you didn't want to?
___ forced particular unwanted sexual acts?
___ forced sex when you were sick or it was a danger to your
health?
___ committed sadistic sexual acts?
___ forced you to have sex after a beating?
Psychological and Emotional Abuse:
___ ridiculed or insulted people you like?
___ become angry or upset, dampening your enthusiasm just before
or during a social event you've looked forward to?
___ created a situation where you felt uneasy being with your
partner and your friends at the same time?
___ created a situation where you felt nervous or frightened
of what your partner would say or do if you are even a few minutes late
from work, shopping or visiting others?
___ created a situation where you felt you needed to speak carefully
or avoid speaking so you won't risk upsetting your partner?
___ ridiculed the traits you admire or value most in yourself?
___ told you no one else would want you?
___ urged you to apologize for things you didn't do?
___ threatened to make public the things you've done or said
in private moments?
___ threatened suicide or excessive drinking to keep you from
leaving?
___ suggested you're "stupid" or "crazy" if you disagreed with
her?
___ apologized and said the abuse was a sign of deep love and
fear of losing you?
___ after abusing you expressed so much sorrow, guilt or self-hate
that you became the one who comforted your partner?
___ threatened to bring you "out" to friends, relatives or employers
if you don't do what she wants you to do?
___ refused to confide in you when she was worried, hurt or scared?
___ made it so you can't ask for help or emotional support from
your partner?
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