This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
Figure 2. Excerpts from the Domestic Violence Survivor Assessment Form: Issues about the Relationship—Medical Care for Domestic Violence Injuries and Stress
|Ignores stress and injuries when with others. Copes alone.
Committed to continuing.
|For safety, delays care and counseling/therapy. Seeks initial treatment; lies regarding abuse.
Considers change: abuse and options
|Uses medical care and counseling/therapy. May have ongoing health and emotional problems from domestic violence.|
Establishes a new life—apart or together.
Source: Jacqueline Dienemann, Visiting Professor, University of North Carolina at Charlotte, Department of Adult Health Nursing, 9201 University City Boulevard, Charlotte, NC 28223; E-mail: firstname.lastname@example.org or email@example.com. Used with permission.
Return to Document