Domestic Violence Screening Form printable pdf download

DOMESTIC VIOLENCE

SCREENING

Date: _______________________ID # ________________________

Time:_______________________ Patient DOB__________________

DV Screen

Patient Name: _____________________________________________

� DV+ (Positive)

Provider Name:____________________________________________

� DV+ (Suspected)

DANGER ASSESSMENT

Indicate on the drawing of the body above anywhere you have been hurt by your current partner.

Indicate any place a weapon has been used.

Several risk factors havwe been associated with homicides (murder) of both batterers and battered women/men through research which has been

conducted after the killings have taken place. We cannot predict what will happen in your case, but we would like you to be aware of the

danger of homicide in situations of severe battering and to see how many of the risk factors apply to your situation. The s/he in the question

refers to husband, wife, life partner, ex-husband, ex-wife, ex-partner, or whoever is physically hurting you.

Please check YES or NO for each question.

� YES

Is the abuser here now?

� NO

� YES

Is patient afraid of their partner?

� NO

� YES

Is patient afraid to go home?

� NO

� YES

Has physical violence increased in frequency?

� NO

� YES

Has physical violence increased in severity?

� NO

� YES

Does abuser ever try to choke you?

� NO

� YES

� NO

Threats of homicide?

� YES

� NO

Does abuser control daily activities (i.e. use of money, transportation, friends)?

If abuser tries, but you do not allow it, check here ____.

� NO

� YES

Is abuser violently and constantly jealous of you (i.e. "If I can't have you, no one can")?

� NO

� YES

10.

Alcohol or substance abuse?

� YES

� NO

11.

Threats of suicide? By whom: _____________________________________________

� YES

� NO

12.

Is there a gun in the house?

� YES

� NO

13.

Has partner physically abused children?

� YES

� NO

14.

Have children witnessed violence in the home?

� YES

� NO

15.

Has patient discussed a safety plan with anyone?

Domestic Violence Screening Form

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