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Marital Abuse Screen

This screen is a measure of emotional and physical abuse.
Answer all the questions.  Skipping any question will not give the correct result.
Check the one that applies to how you have been feeling for the past six months.

  # Questions  No Yes
   1 I feel my spouse belittles and insults me.
   2 My spouse gets very upset when things are not done the way he/she thinks it should be done.
   3 My spouse acts as if I am his/her personal servant.
   4 My spouse interrogates me about money I spend on myself.
   5 My spouse makes me perform sex acts that I do not enjoy or like.
   6 My spouse does not respect my feelings.
   7 My spouse acts like she/he would like to kill me.
   8 My spouse tells me that I am ugly, fat or unattractive.
   9 I am scared of my spouse.
 10 My spouse is jealous and suspicious of my friends.
 11 My spouse gets very angry if I disagree with him/her.
 12 My spouse has hit (slapped or punched) me.
 13 I have needed medical attention when my spouse hit me.
 14 My spouse has threatened me with a weapon (knife, gun).
 15    My spouse has pushed and shoved me.

Personal Information: (Optional)

The information below is for research purposes only.  
It will not reflect on your result.
It will not be used for any other purpose.

  1   Age Range:   
13 - 19yrs       20 -29yrs      30 - 39yrs       40 - 49yrs    
50 - 59yrs      60 - 69yrs      70 - 79yrs       80 - 89yrs    

  2   Gender:     Male         Female      

  3   Marital Status:   
Single     Married     Divorced     Widow/Widower 

  4   Work Status:   Employed     Unemployed      

  5   Education:   
Did not finish High School      High School     
College (2 years)      College (4 years)     Post Graduate   

  6   Have you received treatment for any mental health disorder?    
Yes      No   

  7   I have:   
Depression      Anxiety Disorder      PTSD      Schizophrenia
Manic-Depressive Illness      Obsessive-Compulsive Disorder     
Anorexia     Bulimia    
Addictions: (Alcohol/Drugs    Gambling    Sexual/Pornography )
       
  8   What form of treatment did you receive?  
Medication      Psychotherapy      Both      None

  9   Who did you seek treatment from?  
Physician      Psychiatrist     Psychotherapist/Counselor     Imam

 10  My religion is: Islam     Other