Have you done any of these things [involving sexual intimate partner violence] in the past 12 months?

Has any male partner ever physically encouraged you to have sex or forced you to have sexual intercourse in a humiliating way?

Have you ever forced your current or previous wife or partner to watch pornography when she did not want to?

Have you ever had sex with your current or previous wife or girlfriend when you knew she didn’t want it but you believed she should agree because she was your wife/partner?

Have you ever forced your current or previous wife or partner to do something sexual that she did not want to do?

Have you ever forced an ex-girlfriend or ex-wife to have sex when she did not want to?

Has any male partner ever threatened to use or used a firearm, knife or other weapon against you?

Has any male partner ever slapped or threw something in your direction that could hurt you?

Has any male partner ever kicked, dragged, hit, tried to hang or burned you?

Has any male partner ever pushed you?