Questionnaire

2. When you have finished, put the questionnaire inside the special envelope we have provided, seal the envelope and post it in the box at reception.

3. If you prefer, feel free to take the questionnaire home and finish it there. If you decide to do this, p1ease return the questionnaire to the box at reception in your doctors surgery, or post it in the freepost provided - you won't need a stamp.
 
 

Fiona Bradley (GP)

Mary Smith (Nurse Researcher)

Department of General Practice

UCD

Tel 01-4730693
 
 
 
 

PrID 
 
 

PtID 
 
  Introduction …
 
 

Thank you for helping us with our research. Please answer the following questions for us. For most questions this will involve marking with a tick [ü ] the answer that best applies to you. For example:

                               Do you have a medical card ? [ ] Yes [ ] No

1. What age are you ? l am _____________years old

2. Have you ever been in a close (sexual) relationship?

[ ] Yes, but I am not in a relationship at the moment

[ ] No, I have never been in a close relationshipIf you are in a close relationship now, is it with……

[ ] on my own

[ ] other (please specify)______________________4. Do you have children? [ ] Yes [ ] No

6. Are you currently in paid work?

7. What is your present or most recent occupation?

________________________________________________________________________________________________________________________________________________________

8. Are you/were you

[ ] A manager [ ] A supervisor [ ] An employee

[ ] Self employed [ ] Other (please specify) ______________________
 
 

9. How many drinks of alcohol have you had in the last week? (including beer, wine and spirits)

[ ] None [ ] 1 to 14 [ ] 15 to 28 [ ] More than 28

10. Is there anyone in your household whose drinking is a cause for concern?

[ ] No [ ] Yes If yes, please say who ____________________

11. Is there anyone in your household whose use of drugs is a cause for concern?

[ ] No [ ] Yes If yes, please say who ____________________

These questions are about feelings and emotions. Please read each part, and mark with a [ü ] the reply that comes closest to describing how you have been feeling in the PAST WEEK. Don’t take too long over your replies; your immediate reaction to each item is probably better than a long thought out response.

I feel tense or ‘wound up’:

[ ] A lot of the time

[ ] From time to time, occasionally

[ ] Not at allI still enjoy the things I used to enjoy:

[ ] Not quite so much

[ ] Only a little

[ ] Hardly at allI get a sort of frightened feeling as if something awful is about to happen:

[ ] Yes, but not too badly

[ ] A little, but it doesn’t worry me

[ ] Not at allI can laugh and see the funny side of things:

[ ] Not quite so much now

[ ] Definitely not so much now

[ ] Not at allWorrying thoughts go through my mind:

[ ] A lot of the time

[ ] From time to time but not too often

[ ] Only occasionallyI feel cheerful:

[ ] Not often

[ ] Sometimes

[ ] Most of the timeI can sit at ease and feel relaxed:

[ ] Usually

[ ] Not often

[ ] Not at allI feel as if I am slowed down:

[ ] Very often

[ ] Sometimes

[ ] Not at allI get a sort of frightened feeling like ‘butterflies’ In the stomach:

[ ] Occasionally

[ ] Quite often

[ ] Very OftenI have lost interest in my appearance:

[ ] I don’t take so much care as I should

[ ] I may not take quite as much care

[ ] I take just as much care as everI feel restless as if I have to be on the move:

[ ] Quite a lot

[ ] Not very much

[ ] Not at allI look forward with enjoyment to things:

[ ] Rather less than l used to

[ ] Definitely less than I used to

[ ] Hardly at allI get sudden feelings of panic:

[ ] Quite often

[ ] Not very often

[ ] Not at allI can enjoy a good book or radio or TV program :

[ ] Sometimes

[ ] Not very often

[ ] Very SeldomSection 3 - Violence in relationships …..

These questions explore whether you have experienced violence in a relationship with a partner or previous partner. Please mark with a tick [ü ] the answer that best applies to you.

How often has your current partner or previous partner ever done any of the following things so that you have had to be careful about what you said or did?
 
 

(Please answer all the questions)

1. Threatened you [ ] [ ] [ ] [ ]

2. Shouted, screamed or swore at you [ ] [ ] [ ] [ ]

3. Checked your movements [ ] [ ] [ ] [ ]

4.Restricted your social life [ ] [ ] [ ] [ ]

5.Kept you short of money [ ][ ] [ ] [ ]

6.Criticised you [ ] [ ] [ ] [ ]

7. Put you down in front of others [ ] [ ] [ ] [ ]

8. Shouted at or threatened the kids [ ] [ ] [ ] [ ]
(in ways that might hurt them)

[ ] a previous partner(s)

[ ] current partner and previous partner

[ ] doesn’t apply, never experienced them

11. If you ever experienced any of these things, did they happen

[ ] In the last 12 months on1y

[ ] In the last l2 months &before that

[ ] Before the last l2 months only

[ ] Doesn’t apply, never experienced them
 
 
  12. Please could you tell us whether your present partner or a previous partner has done any of the following things? (please tick one box for each line)

Never Rarely Sometimes Often
[ ] [ ] [ ] [ ] Stopped you from moving or leaving the room
[ ] [ ] [ ] [ ] Choked you or held a hand over your mouth
[ ] [ ] [ ] [ ] Punched you in the face
[ ] [ ] [ ] [ ] Forced you to do something against your will
[ ] [ ] [ ] [ ] Slapped you on the body, arms or legs
[ ] [ ] [ ] [ ] Pushed, grabbed or shoved you
[ ] [ ] [ ] [ ] Punched/kicked you on body, arms or legs
[ ] [ ] [ ] [ ] Used an object to hurt yon
[ ] [ ] [ ] [ ] Threw things at you or about the room
[ ] [ ] [ ] [ ] Punched or kicked walls or furniture
[ ] [ ] [ ] [ ] Demanded sex when you didn’t want it

13. Please could you tell us whether your present partner or a previous partner has done any of the following things? (please tick one box for each line)

Never Rarely Sometimes Often
[ ] [ ] [ ] [ ] Shouted at or threatened the kids
[ ] [ ] [ ] [ ] Hit and hurt the kids
[ ] [ ] [ ] [ ] Forced you to have sex
[ ] [ ] [ ] [ ] Tried to strangle, burn or drown you
[ ] [ ] [ ] [ ] Threatened you with an object or weapon
[ ] [ ] [ ] [ ] Kicked you in the face
[ ] [ ] [ ] [ ] Threatened to kill you
[ ] [ ] [ ] [ ] Twisted your arm or pulled you by the hair
[ ] [ ] [ ] [ ] Threatened you with a fist, hand or foot
 
 

14. lf you ever experienced any of these things was it carried out by

[ ] a previous partner (s)

[ ] current partner and previous partner

[ ] doesn’t apply, never experienced them15.If you ever experienced any of these things, did they happen

[ ] ln the last l2 months & before that

[ ] Before the last 12 months only

[ ] Doesn’t apply, never experienced them
  16. Have you ever had any of the following injuries as the result of the sort of incidents mentioned on the previous pages (Ql2 and 13)?

[ ] Cuts anywhere on your body

[ ] Bruises anywhere on your body

[ ] Burns anywhere on your body

[ ] Broken arm, leg or ribs

[ ] Miscarriage

[ ] Blackout or unconsciousness

[ ] Black eye

[ ] Internal injury

[ ] Lost or broken teeth or split lip

[ ] Sickness or vomiting

[ ] Sprained wrist or ankle

[ ] Broken nose, jaw or cheekbone
[ ] Bleeding on face, body, arms or legs
[ ] Burst ear-drum or deafness
  17. If you ever experienced any of these things was it carried out by

[ ] a previous partner

[ ] current partner and previous partner

[ ] doesn’t apply, never experienced themSection 4 - Your doctor and your practice …

The last few questions are designed to find out whether your doctor has ever talked with you about close relationships. Remember, your doctor will not see your questionnaire, and won’t know the answers you give. When we ask about your doctor, we mean the doctor you usually see.

1. Is your doctor [ ] A man [ ] A woman

2. Do you have a medical card? [ ] Yes [ ] No

Has your doctor ever asked you about…..

Yes No

3. Your partner or a previous partner threatening you? [ ] [ ]

4. Being hit or injured by your partner or a previous partner? [ ] [ ]

5. Being forced to have sex by your partner or a previous partner? [ ] [ ]

6. Would it be all right for your doctor to ask you about abuse or violence in relationships? [ ] Yes [ ] No [ ] Unsure

7. If you were coming to the surgery about something else …..

      [ ] Yes [ ] No [ ] Unsure
 
  12. If a nurse did ask you about these very personal issues, do you think you would be able to answer honestly?

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________Please use this space to add any comments you wish to make.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Now please check you have answered all questions. When you have done that, put the questionnaire inside the special envelope we have provided, seal the envelope and post it in the box at reception.