The patient’s history of abuse (ages, dates, how often)

How does the patient feel about talking about the abuse – who else
have they told?
What does the patient hope will happen if they talk to you – Do they
want you to report the abuse or not?
Is the patient in any danger?
Is the abuse affecting any other victim?
How does the patient respond to the abuse (present response and past
response)
Does the abuse contribute to any emotional distress or dysfunctional
behaviors on the part of the patient?
Have there been an injuries, physical signs or symptoms?
Explore after gathering the data and presenting the case to faculty:
What kind of treatment or action plan can you enlist the patient in?
What kinds of information can you give the patient?
Can you educate the patient about the risks?
Can you assist the patient in developing a safety plan?

Do you feel safe at home?

If you answer NO – why do you not feel safe:
2. We all have disagreements at times, when you and your partner or
family member
argue, have you ever been threatened? If so, how?

Hurt you physically?

Insult or talk down to you?
Threaten you with physical harm?
Scream or curse at you?

3. Do you feel your partner or family member controls (or tries to

control) your behavior
too much of the time? If so, how?
4. Does he/she threaten you – either by saying something or acting in a
certain way? If
so, what ways?
5. Has your partner or family member ever hit, pushed, shoved,
punched or kicked you?
Please tell me about this.
6. Have you ever felt forced to engage in unwanted sexual acts or
sexual contact with
your partner or family member? Please tell me about this.
7. Would you like to discuss this with anyone? Who around you can
you talk to?

Has the amount of physical violence increased in frequency and

severity over the
past year?
2. How often does he/she attack, hit or threaten you?
3. Have you ever been hospitalized as a result of abuse?
4. Has he/she ever threatened you with a weapon?
5. Has he/she ever used a weapon for other reasons?
6. Is there a weapon in the house?
7. Has he/she ever tried to strangle you?
8. Has he/she ever threatened to kill you?
9. Have you ever been afraid you might die while he/she was
attacking you?
10.Does he/she use drugs such as amphetamines (speed), angel
dust (PCP), cocaine or
crack?
11.How often does he/she get drunk?
12.Does he/she control your daily activities, such as where you
go, who you can
spend time with, or how much money you can have?
13.Did he/she ever beat you when you were pregnant?
14.Is he/she violent and constantly jealous of you?
15.Has he/she ever said that if he/she can’t have you, no one else
can?
16.Has he/she ever used threats of suicide or tried to commit
suicide in order to get
you to do what he/she wants you to do?
17.Have you ever threatened suicide or attempted suicide
because of problems in this
relationship?
18.Are you thinking of killing yourself now? If yes, do you have a
plan? A weapon?
19.Is he/she violent toward your children?
20.Is he/she violent outside of your home with others?
21.Are you thinking of killing or harming him/her?
22.Do you think it is safe for you to go home now?

Confidentiality, summarized, picked up the patient was stressed

Abdominal pain for a couple of months, come and go, doesn’t improve with warm water,
medication, occurs at night, dosent eat a good diet. Also light headness. Pain around belly
button, lasting diff everytime, cramping pain doesn’t not radiate, nothing helps with the pain.
5/10. Pt feels difficult to concentrate at work, pt don’t understand what might be causing the
pain. Pt can still function, but pain is interfering with her client （ wedding planner）.

No significant childhood illness, endometriosis had laprospcy, no known allergy, currently no on

medication, took asa for abdominal pain, ibuprofen for menstral cramp. Last menstrual was 2
weeks ago. Father had HTN, mother had cataract. No kids, since had laproscopy.

Lives with husband in house in nice neighbor, degree in business, works as manager wedding
planner. Leisure: yoga with friends, but too busy with work for the past year. Used to go to
church, but now too busy with work, wears seat belt, has fire alarm in house, do not have
weapon at home. Talk with friends at yoga, and sister (not in sxm), and parents (in 70s).
husband doesn’t like it when she doenst answer the phone, seems really stressed about
husband calling, bruising on arm.
No fevers, night sweats, weight loss 3 lb recently. Diarrhea, and constipation, didn’t notice
blood or particles in stool.

Heart palpitate
Husband got laid off, drinks, gets uncontrolled, gets violent and aggressive. Hurts her physically
(pulls her, grabs her, kicks her) multiple times (once a week), last happened few days ago. He
insults her and talks down on her, tries to control her where she is and who she is. Screams at
pt. doesn want to report on husband because want to help her husband, but don’t want others
to know about it. Doesn’t talk to sister about it. Went to ER since she fell on her back, broke her
arm, in cast for 6-8 weeks, husband was apologetic but went back to drinking again.