1) Have you ever been emotionally or physically abused by your partner or someone important to you?

Yes… No…

If yes, by whom?

Husband… Ex-husband… Boyfriend… Ex-boyfriend… Stranger… Other…

Number of times…

2) In the course of the year prior to becoming pregnant, were you ever hit, kicked, shoved or otherwise physically hurt by someone?

Yes… No

If yes, by whom?

Husband… Ex-husband… Boyfriend… Ex-boyfriend… Stranger… Other…

Number of times…

3) In the course of your pregnancy, were you ever hit, kicked, shoved or otherwise physically hurt by someone?

Yes No

If yes, by whom?

Husband… Ex-husband… Boyfriend… Ex-boyfriend… Stranger… Other…

Number of times…

4) Have you ever been forced to participate in or been subjected to sexual activity against your will?

Yes No

If yes, by whom?

Husband… Ex-husband… Boyfriend… Ex-boyfriend… Stranger… Other…

Number of times…

5) Have you ever been afraid of your partner or anyone you have mentioned here?

Yes No