How often has your husband threatened to use or actually used a gun, knife or other weapon against you?

How often has your husband slapped you or thrown something at you that could hurt you?

How often has your husband pushed you, cornered, or pulled your hair?

How often has your husband kicked, dragged, beaten you?

How often has your husband hit you with a fist or with something else that could hurt you?

How often has your husband choked or burned you on purpose?

Have you threatened to use or actually used a gun, knife or other weapon against your wife in the last twelve months?

Have you slapped your wife or thrown something at her that could hurt her in the last twelve months?

Have you pushed, cornered, or pulled your wife’s hair in the last twelve months?

Have you hit your wife with a fist or with something else that could hurt her in the last twelve months?