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Abuse Survey

Abuse Survey

...Date:___________, By:___________, For:___________
{Directions: please answer Sometimes, Often or Always.
To answer never, leave it blank.}
PHYSICAL: Does this person:
_____ demand reports on your activities? _____ grill you?
_____ glare at you? _____ show anger in your presence?
_____ talk loudly? _____ yell? _____ lose control?
_____ pound a fist? _____ throw or break things?
_____ get angry just before a social event?
_____ hold you to keep you from leaving?
_____ physically force you to do things you don't want to?
_____ treat you roughly-- grab, pinch, push, shove, etc?
VERBAL: Does this person THREATEN to:
_____ leave you?
_____ reveal things you've said in private?
_____ punish you if you misbehave?
_____ take your car keys or checkbook?
_____ commit suicide or go crazy if you leave?
Does this person:
_____ correct you?
_____ criticize you?
_____ call you names?
_____ use sarcasm or ridicule?
_____ blame you or self or others?
EMOTIONAL: Is this person:
_____ touchy about being or feeling controlled?
_____ touchy about having personal rights and feelings considered?
Does this person:
_____ ignore your feelings and wants?
_____ refuse to confide in you?
_____ lie about little things?
_____ lie about big things?
_____ use intimidation to "get my way"?
_____ complain or ignore you when you ask for emotional support?
_____ complain or ignore you when you're sick and need care?
_____ have a hard time expressing feelings, reassurance, praise?
_____ take what's wanted without regard for other's feelings?
_____ assume you and other people are hostile?
_____ embarrass you in front of people?
_____ make you feel ashamed?
_____ force you to apologize for things you didn't do?
_____ make you feel unworthy?
_____ flirt with others in your presence?
_____ demand your trust rather than try to earn trust?
_____ not believe your feelings are hurt when you say so?
_____ refuse to apologize if you "made me angry"?
_____ isolate you from friends and loved ones?
_____ prevent you from talking to the opposite sex?
_____ claim to be smarter, stronger or better than you?
_____ make you feel you're crazy?
_____ claim you're stupid or crazy if you disagree?
_____ give you affection and special care after hurting you?
_____ expect you to know wants or feelings?
_____ defends from blame, while blaming you?
_____ give contradictory messages, confuse you?
_____ do unrequested favors and then want them returned?
_____ claim the abuse is a sign of deep love, or fear of losing you?
_____ express so much sorrow or guilt after hurting you that you
wind up having to do the comforting?
_____ claim you can't exist or manage alone?
_____ claim no one else would want you?
_____ make you believe there's no way out, no hope?

Do you:
_____ feel scared of this person?
_____ feel overpowered?
_____ even when they're not present?
_____ make excuses for this person to others or yourself?
_____ believe you're the only one who can save this person?
_____ "walk on eggshells" for the sake of peace?
_____ distrust your own feelings?
_____ feel like you've given up?

Here's a version you can download:

Download Emotional_Abuse_Checklist_4_1.rtf