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Evaluation form

This questionnaire examines whether you are a victim of domestic violence or not. Thank you for your honest answer:

Limiting communication with family

Yes
No

Insist on where you have been

Yes
No

Ignorance or indifferent behavior

Yes
No

Getting angry when talking to other men

Yes
No

It is often questionable about spouse fidelity

Yes
No

He expects you to ask his permission when you want to use health care

Yes
No

Keep out of sight of friends

Yes
No

Insults or makes you feel bad about yourself

Yes
No

Insults or humiliates you in front of others

Yes
No

Deliberately causes you fear and intimidation

Yes
No

Threatens or intimidates relatives of his wife

Yes
No

Slaps or throws objects at you

Yes
No

pushing or shoving

Yes
No

Knocking with a fist or anything

Yes
No

Kicking, beating, dragging

Yes
No

Intentional suffocation or burning

Yes
No

Threat or use of weapons

Yes
No

Being Forced to have sex

Yes
No

Being Forced to have sex for fear of partner behavior

Yes
No

Forcing to engage in degrading sexual behavior

Yes
No
Register and submit