Domestic Violence Screening Form

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DOMESTIC VIOLENCE
SCREENING
Date: _______________________ID # ________________________
Time:_______________________ Patient DOB__________________
DV Screen
Patient Name: _____________________________________________
� DV+ (Positive)
Provider Name:____________________________________________
� DV+ (Suspected)
DANGER ASSESSMENT
Indicate on the drawing of the body above anywhere you have been hurt by your current partner.
Indicate any place a weapon has been used.
Several risk factors havwe been associated with homicides (murder) of both batterers and battered women/men through research which has been
conducted after the killings have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the
danger of homicide in situations of severe battering and to see how many of the risk factors apply to your situation. The s/he in the question
refers to husband, wife, life partner, ex-husband, ex-wife, ex-partner, or whoever is physically hurting you.
Please check YES or NO for each question.
� YES
1.
Is the abuser here now?
� NO
� YES
2.
Is patient afraid of their partner?
� NO
� YES
3.
Is patient afraid to go home?
� NO
� YES
4.
Has physical violence increased in frequency?
� NO
� YES
5.
Has physical violence increased in severity?
� NO
� YES
6.
Does abuser ever try to choke you?
� NO
� YES
� NO
7.
Threats of homicide?
� YES
� NO
8.
Does abuser control daily activities (i.e. use of money, transportation, friends)?
If abuser tries, but you do not allow it, check here ____.
� NO
� YES
9.
Is abuser violently and constantly jealous of you (i.e. "If I can't have you, no one can")?
� NO
� YES
10.
Alcohol or substance abuse?
� YES
� NO
11.
Threats of suicide? By whom: _____________________________________________
� YES
� NO
12.
Is there a gun in the house?
� YES
� NO
13.
Has partner physically abused children?
� YES
� NO
14.
Have children witnessed violence in the home?
� YES
� NO
15.
Has patient discussed a safety plan with anyone?
1

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