Optional Health Assessment Modules Form Page 26
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27UR Number:
Surname:
Given name:
Date of birth:
(Please fill in if no label available)
People often have different definitions of physical violence. For the purpose of this survey, we would like you to view behaviours like pushing and shoving
as a “physical attack.”
PHYSICAL VIOLENCE – PAST 30 DAYS
HOW OFTEN HAVE YOU
HOW BOTHERED WERE YOU BY THE
EXPERIENCED THE PROBLEM?
PROBLEM?
38. Your loved one threatened to physically attack you
0
1
2
3
4
0
1
2
3
4
39. Your loved one actually physically attacked you
0
1
2
3
4
0
1
2
3
4
40. Your loved one actually physically hurt you
0
1
2
3
4
0
1
2
3
4
41. You threatened to physically attack your loved one
0
1
2
3
4
0
1
2
3
4
42. You actually physically attacked your loved one
0
1
2
3
4
0
1
2
3
4
43. You actually physically hurt your loved one
0
1
2
3
4
0
1
2
3
4
44. Your loved one threatened to physically attack a family member
0
1
2
3
4
0
1
2
3
4
other than you
45. Your loved one actually physically attacked a family member other
0
1
2
3
4
0
1
2
3
4
than you
46. Your loved one actually physically hurt a family member other than
0
1
2
3
4
0
1
2
3
4
you
47. Another family member threatened to physically attack your loved
0
1
2
3
4
0
1
2
3
4
one
48. Another family member actually physically attacked your loved one
0
1
2
3
4
0
1
2
3
4
49. Another family member actually physically hurt your loved one
0
1
2
3
4
0
1
2
3
4
50. Your loved one injured him/herself on purpose
0
1
2
3
4
0
1
2
3
4
51. Your loved one intentionally damaged or destroyed property or
0
1
2
3
4
0
1
2
3
4
possessions
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
25
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