History of violence questionnaire Description of incidents: Was the violence witnessed by adults in the family? YES NO Was the violence witnessed by children in the family? YES NO Was any violence experienced by other family members? YES NO Dates of incidents: ........................................ ........................................ ........................................ ........................................ ........................................ PHYSICAL ASSAULTS: Slapping or kicking or punching Blows with rifle butts, sticks, whips, irons Exposure to extreme cold or heat Hanging or suspension Prolonged standing or crouching Submarine,immersion,asphyxiation, strangling Burnings Electrical shocks Rape Total number of Physical Assaults DEPRIVATION: Deprived of food,comfort or communication Incommunication,minimal food and comfort, overcrowding for more than 23 days Lack of water (more than 48 hours) Immobilization,restraint,total darkness (more than 48 hours) Lack of sleep (less than 4 hours per night) for 5 days or longer Lack of needed medication or medical care for more than 48 hours Total number of Deprivation SENSORY OVERSTIMULATION: Constant noises Screams and voices Powerful lights Constant lighting Special devices Drugs Total number of Sensory Overstimulation PSYCHOLOGICAL TORTURE AND ILL TREATMENT: Verbal abuse Threats against person False accusations Abuse with excrement YES NO YES YES YES YES NO NO NO NO YES YES YES YES NO NO NO NO YES NO YES YES NO NO YES NO YES NO YES NO YES YES YES YES YES YES NO NO NO NO NO NO YES YES YES YES NO NO NO NO