Male and Female Perpetrated Partner Abuse: Testing a
Diathesis-Stress Model
by Reena Sommer
Appendix B
Appendix B
Independent Measures
Part 1: Demographic Information
Please describe the following characteristics about yourself.
1. When were you born?
day . . . . . . . . . . . . . . . . . . . . . . . . . . ____
month . . . . . . . . . . . . . . . . . . . . . . . . . ____
year. . . . . . . . . . . . . . . . . . . . . . . . . . 19__
2. What is your gender?
Male . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Female . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
3. What is your marital status?
Single . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Married. . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Living with partner. . . . . . . . . . . . . . . . . . . .[ ]
Widowed. . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Separated. . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Divorced. . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Married, but previously divorce. . . . . . . . . . . . . .[ ]
4. How many times have you been divorced?
Number of times . . . . . . . . . . . . . . . . . . . . . ____
5. Has there been any change in your marital status in the past two
years?
Yes. . . . . . . . . . . . . . . . . . . . .. . . . . . .[ ]
No . . . . . . . . . . . . . . . . . . . . . . . .. . . .[ ]
6. What has been the change to?
Married. . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Remarried . . . . . . . . . . . . . . . . . . . . . . . . [ ]
Separated. . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Divorced . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Widowed. . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
7. What is the highest grade you attended or degree/diploma you received?
some grade school. . . . . . . . . . . . . . . . . . . . .[ ]
completed grade school . . . . . . . . . . . . . . . . . .[ ]
some high school . . . . . . . . . . . . . . . . . . . . .[ ]
completed high school. . . . . . . . . . . . . . . . . . .[ ]
some college or technical diploma. . . . . . . . . . . . .[ ]
university graduate. . . . . . . . . . . . . . . . . . . .[ ]
some post graduate work. . . . . . . . . . . . . . . . . .[ ]
master's degree or doctorate . . . . . . . . . . . . . . .[ ]
8. What is your current employment status?
working full time. . . . . . . . . . . . . . . . . . . . .[ ]
working part time. . . . . . . . . . . . . . . . . . . . .[ ]
unemployed, but looking for work . . . . . . . . . . . . .[ ]
full time student. . . . . . . . . . . . . . . . . . . . .[ ]
part time student. . . . . . . . . . . . . . . . . . . . .[ ]
retired. . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
other. . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
9. In your most recent job, what was/is your title?
_______________________________________________________________
10. What is your spouse/partner's employment status?
working full time. . . . . . . . . . . . . . . . . . . . .[ ]
working part time. . . . . . . . . . . . . . . . . . . . .[ ]
unemployed, but looking for work . . . . . . . . . . . . .[ ]
full time student. . . . . . . . . . . . . . . . . . . . .[ ]
part time student. . . . . . . . . . . . . . . . . . . . .[ ]
retired. . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
other. . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
do not have a spouse/partner . . . . . . . . . . . . . . .[ ]
11. So that we can compare this study with the whole
population by
broad income groups, indicate
your income for the past year
(that is, total income before
taxes, including wages, welfare
income, farm income, interest,
dividends, etc.) of all members
of the family presently
residing in this household by circling
one of these income categories.
Under $10,000. . . . . . . . . . . . . . . . . . . . . . .[ ]
$10,000-$20,0000 . . . . . . . . . . . . . . . . . . . . .[ ]
$20,000-$35,0000 . . . . . . . . . . . . . . . . . . . . .[ ]
$35,000-$50,0000 . . . . . . . . . . . . . . . . . . . . .[ ]
Over $50,000 . . . . . . . . . . . . . . . . . . . . . . .[ ]
Don't know . . . . . . . . . . . . . . . . . . . . . . . .[ ]
12. What is your religion?
Catholic . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Protestant . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Jewish . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Other. . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No religious preference. . . . . . . . . . . . . . . . . .[ ]
13. What is your racial background?
White. . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Black. . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Asian. . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Native . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Other. . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
14. To which ethnic or cultural group do you feel you belong?
_____________________________________________________________
Screening for alcohol consumption:
1. Did you yourself drink any alcohol in the last 12 months?
[Any wine, beer or liquor - even a
taste]
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
If NO,
2. Was there ever a time when you drank wine, beer or
liquor or anything
containing alcohol even once?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
[SKIP TO Q. 68]
Part 2: Volume Variability Index (VVI)
THE NEXT QUESTIONS ASK ABOUT YOUR USE OF BEER, WINE AND LIQUOR
OVER THE PAST YEAR.
1. First of all, how often do you usually have wine?
Three or more times a day . . . . . . . . . . . . . . . . .[ ]
Two times a day . . . . . . . . . . . . . . . . . . . . . .[ ]
Once a day. . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Nearly everyday . . . . . . . . . . . . . . . . . . . . . .[ ]
Three or four times a week. . . . . . . . . . . . . . . . .[ ]
Once or twice a week. . . . . . . . . . . . . . . . . . . .[ ]
One to three times a month. . . . . . . . . . . . . . . . .[ ]
Less than once a month but at least once a year . . . . . .[ ]
Less than once a year . . . . . . . . . . . . . . . . . . .[ ]
I have never had wine . . . . . . . . . . . . . . . . . . .[ ]
2. Now, think of all the times you have had wine recently.
When you
drink wine, how many glasses do you usually have?
One or two glasses. . . . . . . . . . . . . . . . . . . . .[ ]
Three or four glasses . . . . . . . . . . . . . . . . . . .[ ]
Five or six glasses . . . . . . . . . . . . . . . . . . . .[ ]
More than six glasses . . . . . . . . . . . . . . . . . . .[ ]
3. About how many times during the past 12 months did you
have eight
or more glasses of wine at a sitting?
Nearly everyday . . . . . . . . . . . . . . . . . . . . . .[ ]
One to three times a week . . . . . . . . . . . . . . . . .[ ]
One to three times a month. . . . . . . . . . . . . . . . .[ ]
Less than once a month. . . . . . . . . . . . . . . . . . .[ ]
Never . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
4. How often do you usually have beer?
Three or more times a day . . .
. . . . . . . . . . . . . .[ ]
Two times a day . . . . . . . .
. . . . . . . . . . . . . .[ ]
Once a day. . . . . . . . . . .
. . . . . . . . . . . . . .[ ]
Nearly everyday . . . . . . . .
. . . . . . . . . . . . . .[ ]
Three or four times a week. . .
. . . . . . . . . . . . . .[ ]
Once or twice a week. . . . . .
. . . . . . . . . . . . . .[ ]
One to three times a month. . .
. . . . . . . . . . . . . .[ ]
Less than once a month but at
least once a year . . . . . .[ ]
Less than once a year . . . . . . . . . . . . . . . . . . .[ ]
I have never had beer . . . . . . . . . . . . . . . . . . .[ ]
5. Now, think of all the times you have had beer
recently. When you
drink beer, how many glasses do you usually have?
One or two
glasses. . . . . . . . . . . . . . . . . . . . .[ ]
Three or four
glasses . . . . . . . . . . . . . . . . . . .[ ]
Five or six glasses
. . . . . . . . . . . . . . . . . . . .[ ]
More than six
glasses . . . . . . . . . . . . . . . . . . .[ ]
6. About how many times during the past 12 months did you
have eight
or more glasses of beer at a sitting?
Nearly everyday
. . . . . . . . . . . . . . . . . . . . . .[ ]
One to three times
a week . . . . . . . . . . . . . . . . .[ ]
One to three times
a month. . . . . . . . . . . . . . . . .[ ]
Less than once a
month. . . . . . . . . . . . . . . . . . .[ ]
Never . . . . . . .
. . . . . . . . . . . . . . . . . . . .[ ]
7. How often do you usually have drinks containing liquor
(such as
Martinis, Manhattans, or straight drinks)?
Three or more times a day. . . . . . . . . . .
. . . . . . [ ]
Two times a day. . . . . . . . . . . . . . . . .
. . . . . [ ]
Once a day . . . . . . . . . . . . . . . . . . .
. . . . . [ ]
Nearly everyday. . . . . . . . . . . . . . . . . . . . . . [ ]
Three or four times a week . . . . . . . . . . .
. . . . . [ ]
Once or twice a week . . . . . . . . . . . . . .
. . . . . [ ]
One to three times a month . . . . . . . . . . .
. . . . . [ ]
Less than once a month but at least once a year.
. . . . . [ ]
Less than once a year. . . . . . . . . . . . . .
. . . . . [ ]
I have never had liquor. . . . . . . . . . . . .
. . . . . [ ]
8. Now, think of all the times you have had liquor
recently. When you
drink liquor, how many drinks do you usually
have?
One or two
drinks . . . . . . . . . . . . . . . . . . . . .[ ]
Three or four
drinks. . . . . . . . . . . . . . . . . . . .[ ]
Five or six drinks.
. . . . . . . . . . . . . . . . . . . .[ ]
More than six
drinks. . . . . . . . . . . . . . . . . . . .[ ]
9. About how many times during the past 12 months did you
have eight
or more drinks of liquor at a sitting?
Nearly everyday
. . . . . . . . . . . . . . . . . . . . . .[ ]
One to three times
a week . . . . . . . . . . . . . . . . .[ ]
One to three times
a month. . . . . . . . . . . . . . . . .[ ]
Less than once a
month. . . . . . . . . . . . . . . . . . .[ ]
Never . . . . . . .
. . . . . . . . . . . . . . . . . . . .[ ]
Part 3: Michigan Alcoholism Screening Test
(Short Form) (SMAST)
HERE ARE SOME MORE QUESTIONS ABOUT EXPERIENCES YOU MAY
HAVE HAD
BECAUSE OF YOUR DRINKING. INDICATE YOUR RESPONSE TO
EACH STATEMENT BY
A "YES" OR "NO".
1. Do you feel you are a normal drinker? (By normal we mean
you drink
less than or as much as most other people).
2. Have you ever gotten into trouble at work because of drinking?
3. Have you had delirium tremens (DT's), severe shaking,
heard voices,
or seen things that weren't there after heavy drinking?
4. Do your friends or relatives think you are a normal drinker?
5. Have you ever attended a meeting of Alcoholics Anonymous?
6. Have you ever lost a boy/girl friend because of your
drinking?
7. Have you ever neglected your obligations, your family,
or your work
for two or more days in a row because you were drinking?
8. Have you ever gone to anyone for help about your drinking?
9. Have you ever been in a hospital because of your drinking?
10. Does your wife, husband, a parent or other near
relative ever
worry or complain about your
drinking?
11. Do you ever feel guilty about your drinking?
12. Are you able to stop drinking when you want to?
13. Has your drinking ever created problems between
you and your
wife, husband, a parent, or other
near relative?
Part 4: Alcohol Dependence Data
Schedule (SADD)
THE FOLLOWING QUESTIONS COVER A WIDE RANGE OF TOPICS TO DO
WITH YOUR
CURRENT DRINKING PATTERNS. USE THE RESPONSE CARDS TO INDICATE
YOUR
ANSWER TO THE QUESTION.
| 1. |
Do you find difficulty in getting the thought of drink
out of your mind? |
Never |
Sometimes |
Often |
Nearly Always |
| 2. |
Is getting drunk more important than your next meal?
|
|
|
|
|
| 3. |
Do you plan your day around when and where
you can drink? |
|
|
|
|
| 4. |
Do you drink in the morning, afternoon and evening
(i.e., during the same day)? |
|
|
|
|
| 5. |
Do you drink for the effect of alcohol without caring
what the drink is? |
|
|
|
|
| 6. |
Do you drink as much as you want irrespective of what
you are doing the next day? |
|
|
|
|
| 7. |
Given that many problems are caused by alcohol, do you
still drink too much? |
|
|
|
|
| 8. |
Do you know that you won't be able to stop
drinking once you start? |
|
|
|
|
| 9. |
Do you try to control your drinking by giving it up
completely for days or weeks at a time? |
|
|
|
|
| 10. |
The morning after a heavy drinking session, do
you need your first to get yourself going? |
|
|
|
|
| 11. |
The morning after a heavy drinking session, do
you wake up with a definite shakiness of your hands? |
|
|
|
|
| 12. |
After a heavy drinking session, do you wake up
and retch or vomit? |
|
|
|
|
| 13. |
The morning after a heavy drinking session, do
you go out of your way to avoid people? |
|
|
|
|
| 14. |
After a heavy drinking session, do you see
frightening that you later realize were imaginary? |
|
|
|
|
| 15. |
Do you go drinking and the next day find you
have forgotten what happened the night before? |
|
|
|
|
Part 5: Diagnostic Interview Schedule
(DIS III R)
THE FOLLOWING QUESTIONS ASK ABOUT YOUR DRINKING HABITS.
PLEASE CIRCLE
THE NUMBER THAT BEST DESCRIBES YOU. YES [ ] NO [ ]
People differ in their reactions to alcohol. So it
is important that
we ask you first about your experience with wine, beer or
other
alcoholic drinks, and then about the problems some people
have with
alcohol.
1. How old were you when you first had any wine, beer, or
liquor at
least once a month (for 6 months or more)?
year . . . . . . . . . . . . . . . . . . . . . . . . . . 19____
month. . . . . . . . . . . . . . . . . . . . . . . . . . ______
2. What is the largest number of drinks that you've ever
had in one day?
number of drinks . . . . . . . . . . . . . . . .
. . . . ______
3. When did you first have as much as 20 drinks in one day?
year . . . . . . . . . . . . . . . . . . . . . .
. . . . 19____
month. . . . . . . . . . . . . . . . . . . . . .
. . . . ______
4. Has there ever been a period of two weeks when everyday
you were
drinking at least 7 drinks --- that could include
beers, glasses of
wine, or drinks of any kind?
YES. . . . . . . . . . . . . . . . . . . . . .
. . . . . . .[ ]
NO . . . . . . . . . . . . . . . . . . . . . . .
. . . . . .[ ]
5. When did you first have a period of two weeks when you
drank at
least 7 drinks everyday?
year . . . . . . . . . . . . . . . . . . . . .
. . . . . 19____
month. . . . . . . . . . . . . . . . . . . . . .
. . . . ______
6. Has there ever been a couple of months or more when at
least one
evening a week you drank 7 or more drinks or
bottles of beer or
glasses of wine?
YES. . . . . . . . . . . . . . . . . . . . . .
. . . . . . .[ ]
NO . . . . . . . . . . . . . . . . . . . . . . .
. . . . . .[ ]
7. When was the first time that at least one evening a week
you drank
7 or more drinks?
year . . . . . . . . . . . . . . . . . . . . .
. . . . . 19____
month. . . . . . . . . . . . . . . . . . . . . .
. . . . . ____
NEVER [ ]
SOMETIMES [ ]
OFTEN [ ]
NEARLY ALWAYS [ ]
8. Have you ever gone on binges or benders where you kept
drinking for a
couple of days or more without sobering up?
9. Did you neglect some of your usual responsibilities
then?
10. Did you do that several times or go on a binge
that lasted a
month or more?
11. Did you ever get tolerant to alcohol, that is,
you needed to
drink a lot more in order to
get an effect, or found that you
could no longer get high on the
amount you used to drink?
12. After you had been drinking for a while, did you
find that you
began to be able to drink a lot
more before you would get drunk
(before your speech got thick
or you were unsteady on your
feet)?
13. Did your ability to drink more without feeling
it last for a
month or more?
14. Have there been many days when you drank much
more than you
expected to when you began, or
have you often continued drinking
for more days in a row than you
intended to?
15. Have you more than once wanted to stop drinking
but couldn't?
16. Some people try to control their drinking by
making rules, like
not drinking before 5 o'clock
or never drinking alone. Have you
ever made rules like that for
yourself?
17. Did you make these rules because you were having
trouble
limiting the amount you were
drinking?
18. Did you try to follow those rules for a month or
longer or make
rules for yourself several
times?
19. Has there ever been a period when you spent so
much time
drinking alcohol or getting
over its effects that you had little
time for anything else?
20. Did the period when you spent a lot of time
drinking last a
month or longer?
21. Have you ever given up or greatly reduced
important activities
in order to drink --- like
sports, work, or associating with
friends or relatives?
22. Did you give up or cut down on activities to
drink for a month
or more?
23. Has your drinking or being hung over often kept
you from working
or taking care of children?
24. Have you often worked or taken care of children
at a time when
you had drunk enough alcohol to
make your speech thick or to
make you unsteady on your feet?
25. Have you ever had fits or seizures after
stopping or cutting
down on your drinking?
26. Did you ever need a drink just after you had
gotten up (that is,
before breakfast)?
27. Did you take a drink right after you got up to
keep from having
a hangover or the shakes?
28. Have you ever taken a drink to keep from having
withdrawal
symptoms or to make them go
away?
Part 6: Eysenck Personality Questionnaire
-Revised (EPQ-R)
PLEASE ANSWER EACH QUESTION BY PUTTING A TICK IN THE BOX
UNDER THE
"YES" OR THE "NO" FOLLOWING THE QUESTION.
WORK QUICKLY AND DO NOT THINK
TOO LONG ABOUT THE EXACT MEANING OF THE QUESTIONS.
1. Do you have many different hobbies?
YES NO
[ ] [ ]
2. Do you stop to think things over before doing anything?
YES NO
[ ] [ ]
3. Does your mood often go up and down?
YES NO
[ ] [ ]
4. Have you ever taken praise for something you knew
someone else had
really done?
YES NO
[ ] [ ]
5. Do you take much notice of what people think?
YES NO
[ ] [ ]
6. Are you a talkative person?
YES NO
[ ] [ ]
7. Would being in debt worry you?
YES NO
[ ] [ ]
8. Do you ever feel "just miserable" for no
reason?
YES NO
[ ] [ ]
9. Do you give money to charities?
YES NO
[ ] [ ]
10. Were you ever greedy by helping yourself to more
than your share
of anything?
YES NO
[ ] [ ]
11. Are you rather lively?
YES NO
[ ] [ ]
12. Would it upset you a lot to see a child or
animal suffer?
YES NO
[ ] [ ]
13. Do you often worry about things you should not
have done or
said?
YES NO
[ ] [ ]
14. Do you dislike people who don't know how to
behave themselves?
YES NO
[ ] [ ]
15. If you say you will do something do you always
keep your promise
no matter how inconvenient it
might be?
YES NO
[ ] [ ]
16. Can you usually let yourself go and enjoy
yourself at a lively
party?
YES NO
[ ] [ ]
17. Are you an irritable person?
YES NO
[ ] [ ]
18. Should people always respect the law?
YES NO
[ ] [ ]
19. Have you ever blamed someone for doing something
you knew was
really your fault?
YES NO
[ ] [ ]
20. Do you enjoy meeting new people?
YES NO
[ ] [ ]
21. Are good manners very important?
YES NO
[ ] [ ]
22. Are your feelings easily hurt?
YES NO
[ ] [ ]
23. Are all your habits good and desirable ones?
YES NO
[ ] [ ]
24. Do you tend to keep in the background on social
occasions?
YES NO
[ ] [ ]
25. Would you take drugs which may have strange or
dangerous
effects?
YES NO
[ ] [ ]
26. Do you often feel "fed-up"?
YES NO
[ ] [ ]
27. Have you ever taken anything (even a pin or
button) that
belonged to someone else?
YES NO
[ ] [ ]
28. Do you like going out a lot?
YES NO
[ ] [ ]
29. Do you prefer to go your own way rather than act
by the rules?
YES NO
[ ] [ ]
30. Do you enjoy hurting the people you love?
YES NO
[ ] [ ]
31. Are you often troubled by feelings of guilt?
YES NO
[ ] [ ]
32. Do you sometimes talk about things you know
nothing about?
YES NO
[ ] [ ]
33. Do you prefer reading to meeting people?
YES NO
[ ] [ ]
34. Do you have enemies who want to harm you?
YES NO
[ ] [ ]
35. Would you call yourself a nervous person?
YES NO
[ ] [ ]
36. Do you have many friends?
YES NO
[ ] [ ]
37. Do you enjoy practical jokes that can sometimes
really hurt
people?
YES NO
[ ] [ ]
38. Are you a worrier?
YES NO
[ ] [ ]
39. As a child did you do as you were told
immediately and without
grumbling?
YES NO
[ ] [ ]
40. Would you call yourself happy-go-lucky?
YES NO
[ ] [ ]
41. Do good manners and cleanliness matter much to
you?
YES NO
[ ] [ ]
42. Have you often gone against your parents'
wishes?
YES NO
[ ] [ ]
43. Do you worry about awful things that might
happen?
YES NO
[ ] [ ]
44. Have you ever broken or lost something belonging
to someone
else?
YES NO
[ ] [ ]
45. Do you usually take the initiative in making new
friends?
YES NO
[ ] [ ]
46. Would you call yourself tense or
"highly-strung"?
YES NO
[ ] [ ]
47. Are you mostly quiet when you are with other
people?
YES NO
[ ] [ ]
48. Do you think marriage is old fashioned and
should be done away
with?
YES NO
[ ] [ ]
49. Do you sometimes boast a little?
YES NO
[ ] [ ]
50. Are you more easy-going about right and wrong
than most people?
YES NO
[ ] [ ]
51. Can you easily get some life into a rather dull
party?
YES NO
[ ] [ ]
52. Do you worry about your health?
YES NO
[ ] [ ]
53. Have you ever said anything bad or nasty about
anyone?
YES NO
[ ] [ ]
54. Do you enjoy co-operating with others?
YES NO
[ ] [ ]
55. Do you like telling jokes or funny stories to
your friends?
YES NO
[ ] [ ]
56. Do most things taste the same to you?
YES NO
[ ] [ ]
57. As a child were you ever cheeky to your parents?
YES NO
[ ] [ ]
58. Do you like mixing with people?
YES NO
[ ] [ ]
59. Does it worry if you know there are mistakes in
your work?
YES NO
[ ] [ ]
60. Do you suffer from sleeplessness?
YES NO
[ ] [ ]
61. Have people said you sometimes act too rashly?
YES NO
[ ] [ ]
62. Do you always wash before a meal?
YES NO
[ ] [ ]
63. Do you nearly always have a "ready
answer" when people talk to
you?
YES NO
[ ] [ ]
64. Do you to arrive at appointments in plenty of
time?
YES NO
[ ] [ ]
65. Have you often felt listless and tired for no
reason?
YES NO
[ ] [ ]
66. Have you ever cheated at a game?
YES NO
[ ] [ ]
67. Do you like doing things in which you have to
act quickly?
YES NO
[ ] [ ]
68. Is (or was) your mother a good woman?
YES NO
[ ] [ ]
69. Do you often make decisions on the spur of the
moment?
YES NO
[ ] [ ]
70. Do you often feel life is very dull?
YES NO
[ ] [ ]
71. Have you ever taken advantage of someone?
YES NO
[ ] [ ]
72. Do you often take on more activities than you
have time for?
YES NO
[ ] [ ]
73. Are there several people who keep trying to
avoid you?
YES NO
[ ] [ ]
74. Do you worry a lot about your looks?
YES NO
[ ] [ ]
75. Do you think people spend too much time
safeguarding their
future with savings and
insurance?
YES NO
[ ] [ ]
76. Have you ever wished that you were dead?
YES NO
[ ] [ ]
77. Would you dodge paying taxes if you were sure
you could never be
found out?
YES NO
[ ] [ ]
78. Can you get a party going?
YES NO
[ ] [ ]
79. Do you try not to be rude to people?
YES NO
[ ] [ ]
80. Do you worry too long after an embarrassing
experience?
YES NO
[ ] [ ]
81. Do you generally "look before you leap'?
YES NO
[ ] [ ]
82. Have you ever insisted on having your own way?
YES NO
[ ] [ ]
83. Do you suffer from "nerves"?
YES NO
[ ] [ ]
84. Do you often feel lonely?
YES NO
[ ] [ ]
85. Can you on the whole trust people to tell the
truth?
YES NO
[ ] [ ]
86. Do you always practice what you preach?
YES NO
[ ] [ ]
87. Are you easily hurt when people find fault with
you or the work
you do?
YES NO
[ ] [ ]
88. Is it better to follow society's rules than go
your own way?
YES NO
[ ] [ ]
89. Have you ever been late for an appointment or
work?
YES NO
[ ] [ ]
90. Do like plenty of bustle and excitement around
you?
YES NO
[ ] [ ]
91. Would you like other people to be afraid of you?
YES NO
[ ] [ ]
92. Are sometimes bubbling over with energy and
sometimes very
sluggish?
YES NO
[ ] [ ]
93. Do you sometimes put off for tomorrow what you
ought to do
today?
YES NO
[ ] [ ]
94. Do other people think of you as being very
lively?
YES NO
[ ] [ ]
95. Do people tell you a lot of lies?
YES NO
[ ] [ ]
96. Do you believe one has special duties to one's
family?
YES NO
[ ] [ ]
97. Are you touchy about some things?
YES NO
[ ] [ ]
98. Are you always willing to admit it when you have
made a mistake?
YES NO
[ ] [ ]
99. Would you feel very sorry for an animal caught
in a trap?
YES NO
[ ] [ ]
100. When your temper rises, do you find it difficult to
control?
YES NO
[ ] [ ]
Part 7: MacAndrew Alcoholism Scale (MAC)
THE FOLLOWING SECTION CONTAINS A NUMBER OF
STATEMENTS. READ EACH
STATEMENT AND DECIDE WHETHER OR NOT IT DESCRIBES YOU.
IF YOU AGREE
WITH THE STATEMENT AND DECIDES IT DESCRIBES YOU, CHECK THE
BOX UNDER
THE "TRUE" COLUMN. IF YOU DISAGREE WITH THE
STATEMENT AND FEEL IT DOES
NOT DESCRIBE YOU, CHECK THE BOX UNDER THE "FALSE"
COLUMN. PLEASE TRY
TO ANSWER EVERY STATEMENT. REMEMBER TO GIVE YOUR
OPINION OF YOURSELF.
| |
|
True |
False |
| 1. |
I have a cough most of the time? |
[ ] |
[ ] |
| 2. |
I pray several times a week? |
[ ] |
[ ] |
| 3. |
Christ performed miracles such as changing water into
wine. |
[ ] |
[ ] |
| 4. |
Everything is turning out just as the prophets of the
Bible said it
would. |
[ ] |
[ ] |
| 5. |
I do many things which I regret afterwards (I regret
things more or
more often than others seem to). |
[ ] |
[ ] |
| 6. |
I am embarrassed by dirty stories. |
[ ] |
[ ] |
| 7. |
I have had blank spells in which my activities were
interrupted and
I did not know what was going on around me. |
[ ] |
[ ] |
| 8. |
I like to cook. |
[ ] |
[ ] |
| 9. |
I like to read newspaper articles on crime. |
[ ] |
[ ] |
| 10. |
Evil spirits possess me at times. |
[ ] |
[ ] |
| 11. |
My soul sometimes leaves my body. |
[ ] |
[ ] |
| 12. |
As a youngster I was suspended from school one
or more times for
cutting up. |
[ ] |
[ ] |
| 13. |
I am a good mixer. |
[ ] |
[ ] |
| 14. |
I have not lived the right kind of life. |
[ ] |
[ ] |
| 15. |
I think I would the kind of work a forest ranger
does. |
[ ] |
[ ] |
| 16. |
I enjoy a race or a game better when I bet on
it. |
[ ] |
[ ] |
| 17. |
In school I was sometimes sent to the principal
for cutting up. |
[ ] |
[ ] |
| 18. |
I know who is responsible for most of my
troubles. |
[ ] |
[ ] |
| 19. |
The sight of blood neither frightens me nor
makes me sick. |
[ ] |
[ ] |
| 20. |
I have had periods in which I have carried on
activities without
knowing later what I was doing. |
[ ] |
[ ] |
| 21. |
I frequently notice my hands shake when I am
trying to do
something. |
[ ] |
[ ] |
| 22. |
My parents have often objected to the kind of
people I go around
with. |
[ ] |
[ ] |
| 23. |
I have been quite independent and free from
family rule. |
[ ] |
[ ] |
| 24. |
I have few or no pains. |
[ ] |
[ ] |
| 25. |
I sweat very easily even on cool days. |
[ ] |
[ ] |
| 26. |
If I were a reporter I would very much like to
report on
sporting news. |
[ ] |
[ ] |
| 27. |
I seem to make friends as quickly as others. |
[ ] |
[ ] |
| 28. |
I deserve severe punishment for my sins. |
[ ] |
[ ] |
| 29. |
I played hooky from schools quite often as a
youngster. |
[ ] |
[ ] |
| 30. |
I have at times had to be rough with people who
were rude or
annoying. |
[ ] |
[ ] |
| 31. |
I was fond of excitement when I was young (or in
my childhood). |
[ ] |
[ ] |
| 32. |
I enjoy gambling for small stakes. |
[ ] |
[ ] |
| 33. |
If I were in trouble with several friends who
were equally to
blame, I would rather take the
whole blame than give them away. |
[ ] |
[ ] |
| 34. |
While in trains, buses, etc., I often talk to
strangers. |
[ ] |
[ ] |
| 35. |
I readily become one hundred percent sold on a
good idea. |
[ ] |
[ ] |
| 36. |
I have frequently worked under people who seem
to have things
arranged so that they get
credit for good work but are able to
pass off mistakes onto those
under them. |
[ ] |
[ ] |
| 37. |
I would like to wear expensive clothes. |
[ ] |
[ ] |
| 38. |
The one to whom I was most attached and whom I
admired the most
as a child was a woman (mother,
sister, aunt, or other women). |
[ ] |
[ ] |
| 39. |
I am certainly lacking in self-confidence. |
[ ] |
[ ] |
| 40. |
My table manners are not quite as good at home
as when I am out
in company. |
[ ] |
[ ] |
| 41. |
I have never vomited blood or coughed up blood.
|
[ ] |
[ ] |
| 42. |
I used to keep a diary. |
[ ] |
[ ] |
| 43. |
I liked school. |
[ ] |
[ ] |
| 44. |
I am worried about sex matters. |
[ ] |
[ ] |
| 45. |
I have felt that strangers were looking at me
critically. |
[ ] |
[ ] |
| 46. |
I have never been in trouble with the law. |
[ ] |
[ ] |
| 47. |
Many of my dreams are about sex matters. |
[ ] |
[ ] |
| 48. |
I cannot keep my mind on one thing. |
[ ] |
[ ] |
| 49. |
I have more trouble concentrating than others
seem to. |
[ ] |
[ ] |
| 50. |
I do not like to see women smoke. |
[ ] |
[ ] |
| 51. |
Police are usually honest. |
[ ] |
[ ] |
Part 8: Rosenberg Self Esteem Scale
PLEASE READ THE FOLLOWING STATEMENTS AND INDICATE HOW MUCH
YOU AGREE
OR DISAGREE WITH EACH STATEMENT BY PLACING A TICK IN THE
APPROPRIATE
BOX.
| 1. |
I feel I am a person of worth, at least on equal plane
with others. |
Strongly Agree |
Agree |
Disagree |
Strongly Disagree |
| 2. |
I feel that I have a number of good qualities.
|
|
|
|
|
| 3. |
All in all, I am inclined to feel that I am a failure.
|
|
|
|
|
| 4. |
I am able to do things as well as most other people.
|
|
|
|
|
| 5. |
I feel I do not have much to be proud of.
|
|
|
|
|
| 6. |
I take a positive attitude toward myself.
|
|
|
|
|
| 7. |
On the whole, I am satisfied with myself.
|
|
|
|
|
| 8. |
I wish I could have more respect for myself.
|
|
|
|
|
| 9. |
I certainly feel useless at times.
|
|
|
|
|
| 10. |
At times I think I am no good at all.
|
|
|
|
|
Part 9: Trait Anxiety Scale
A NUMBER OF STATEMENTS WHICH PEOPLE HAVE USED TO DESCRIBE
THEMSELVES
ARE GIVEN BELOW. READ EACH STATEMENT AND CIRCLE THE NUMBER OF
THE
RESPONSE WHICH DESCRIBES HOW YOU GENERALLY FEEL. THERE ARE NO
RIGHT
OR WRONG ANSWERS. DO NOT SPEND TOO MUCH TIME ON ANY ONE
STATEMENT
WHICH SEEMS TO DESCRIBE HOW YOU GENERALLY FEEL.
| |
|
Almost Never |
Sometimes |
Often |
Almost Always |
| 1. |
I feel pleasant. |
|
|
|
|
| 2. |
I tire quickly. |
|
|
|
|
| 3. |
I feel like crying. |
|
|
|
|
| 4. |
I wish I could be as happy as others seem to be.
|
|
|
|
|
| 5. |
I am losing out because I can't my mind soon enough.
|
|
|
|
|
| 6. |
I feel rested. |
|
|
|
|
| 7. |
I am "calm, cool and collected".
|
|
|
|
|
| 8. |
I feel that difficulties are piling up so that I cannot
overcome
them. |
|
|
|
|
| 9. |
I worry too much over something that doesn't really
matter. |
|
|
|
|
| 10. |
I am happy. |
|
|
|
|
| 11. |
I am inclined to take things hard.
|
|
|
|
|
| 12. |
I lack self-confidence. |
|
|
|
|
| 13. |
I feel secure. |
|
|
|
|
| 14. |
I try to avoid facing a crisis or difficulty.
|
|
|
|
|
| 15. |
I feel blue. |
|
|
|
|
| 16. |
I am content. |
|
|
|
|
| 17. |
Some unimportant thoughts run through my head
and bother me. |
|
|
|
|
| 18. |
I take disappointments so keenly that I can't
put them out of my
mind. |
|
|
|
|
| 19. |
I am a steady person. |
|
|
|
|
| 20. |
I get a state of tension or turmoil as I think
over my recent
concerns and interests. |
|
|
|
|
Part 10: Barron Ego-Strength Scale
THE FOLLOWING SECTION CONTAINS A SERIES OF
STATEMENTS. READ EACH
STATEMENT AND DECIDE WHETHER OR NOT IT DESCRIBES YOU.
IF YOU AGREE
WITH THE STATEMENT AND DECIDE THAT IT DESCRIBES YOU, CHECK
THE BOX
UNDER THE "TRUE" COLUMN. IF YOU DISAGREE WITH THE
STATEMENT AND FEEL
IT DOES NOT DESCRIBE YOU, CHECK THE BOX UNDER THE
"FALSE" COLUMN.
PLEASE TRY TO ANSWER EVERY STATEMENT. REMEMBER TO GIVE YOUR
OWN
OPINION OF YOURSELF.
| 1. |
During the past few years I have been well most of the
time. |
True |
False |
| 2. |
I am in just as good physical health as most of my
friends. |
|
|
| 3. |
I have never had a fainting spell. |
|
|
| 4. |
I feel weak all over most of the time. |
|
|
| 5. |
My hands have not become clumsy or awkward. |
|
|
| 6. |
I have a cough most of the time. |
|
|
| 7. |
I have a good appetite. |
|
|
| 8. |
I have diarrhoea once a month or more. |
|
|
| 9. |
At times I hear so well it bothers me. |
|
|
| 10. |
I seldom worry about my health. |
|
|
| 11. |
I feel sympathetic toward people who hang onto
their griefs and troubles. |
|
|
| 12. |
I brood a great deal. |
|
|
| 13. |
I frequently find myself worrying about
something. |
|
|
| 14. |
I have met problems so full of possibilities
that I have been unable to make up my mind about
them. |
|
|
| 15. |
I get mad easily and then get over it soon. |
|
|
| 16. |
Whenever I leave home, I do not worry about
whether the door is locked and the windows are
closed. |
|
|
| 17. |
Sometimes some unimportant thought will run
through my mind and bother me for days. |
|
|
| 18. |
Often I cross the street in order not to meet
someone I see. |
|
|
| 19. |
I dream frequently about things best kept to
myself. |
|
|
| 20. |
I go to church almost every week. |
|
|
| 21. |
I pray several times a week. |
|
|
| 22. |
Christ performed miracles such as changing water
into wine. |
|
|
| 23. |
Everything is turning out just like the prophets
in the Bible said it would. |
|
|
| 24. |
I have had some very unusual religious
experiences. |
|
|
| 25. |
I believe my sins are unpardonable. |
|
|
| 26. |
I would certainly enjoy beating a crook at his
own game. |
|
|
| 27. |
When I get bored I like to stir up some
excitement. |
|
|
| 28. |
I can be friendly with people who do things
which I consider wrong. |
|
|
| 29. |
Some people are so bossy that I feel like doing
the opposite of what they request, even though
I know they are right. |
|
|
| 30. |
I like to flirt. |
|
|
| 31. |
I am attracted by members of the opposite sex.
|
|
|
| 32. |
I never attend a sexy show if I can avoid it. |
|
|
| 33. |
I like to talk about sex. |
|
|
| 34. |
Sometimes I enjoy hurting people I love. |
|
|
| 35. |
I have had very peculiar and strange
experiences. |
|
|
| 36. |
I have strange and peculiar thoughts. |
|
|
| 37. |
When I am with people, I am bothered by hearing
very queer things. |
|
|
| 38. |
At times I have fits of laughing and crying that
I cannot control. |
|
|
| 39. |
I have no difficulty in keeping my balance in
walking. |
|
|
| 40. |
Parts of my body often have feelings like
burning, tingling, crawling or like "going to
sleep". |
|
|
| 41. |
My skin seems to be unusually sensitive to
touch. |
|
|
| 42. |
In my home we have always had the ordinary
necessities (such as enough food, clothing, etc.). |
|
|
| 43. |
I am easily downed in an argument. |
|
|
| 44. |
I find it hard to keep my mind on a task or a
job. |
|
|
| 45. |
My way of doing things is apt to be
misunderstood by others. |
|
|
| 46. |
I sometimes feel that I am about to go to
pieces. |
|
|
| 47. |
I feel tired a good deal of the time. |
|
|
| 48. |
If I were an artist I would like to draw
flowers. |
|
|
| 49. |
If I were an artist I would like to draw
children. |
|
|
| 50. |
I like collecting flowers or growing
houseplants. |
|
|
| 51. |
I am made nervous by certain animals. |
|
|
| 52. |
Dirt frightens or disgusts me. |
|
|
| 53. |
I am afraid of finding myself in a closet or in
a small closed space. |
|
|
| 54. |
I have often been frightened in the middle of
the night. |
|
|
| 55. |
I like science. |
|
|
| 56. |
I very much like horseback riding. |
|
|
| 57. |
The man who had most to do with me when I was a
child (such as my father, stepfather etc.) was
very strict with me. |
|
|
| 58. |
One or more members of my family is very
nervous. |
|
|
| 59. |
My sleep is fitful and disturbed. |
|
|
| 60. |
When someone says ignorant things about
something I know about, I try to set him/her right. |
|
|
| 61. |
I feel unable to tell anyone all about myself.
|
|
|
| 62. |
My plans have frequently seemed so full of
difficulties that I have had to give them up. |
|
|
| 63. |
I am not afraid of fire. |
|
|
| 64. |
Policemen are usually honest. |
|
|
Part 11: Stress
1. Have you lost a job or been unemployed in the past two
years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
If yes,
2. Exactly, how long ago?
number of years ago. . . . . . . . . . . . . . . . . . . .____
number of months ago . . . . . . . . . . . . . . . . . . .____
3. Has your spouse/partner started working within the past
two years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
4. Has your spouse/partner lost a job within the last two
years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
5. Have you had any financial problems in the past two
years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
6. Have you quit or retired from work in the last two
years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
7. Have you stopped going to school in the past two years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
8. Have you moved in the past two years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
9. Has someone moved in with you during the past two years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
10. Do you have any children?
Yes . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . .
. . . . . . . . . . . . .[ ]
11. Have you had a baby in the past two years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
12. Has someone moved out of your home in the past
two years?
Yes . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
No . . . . . . . . . . . . . . . . . . . . . . . . . . .[ ]
Part 12: Family Background
1. Are you currently married or living with your partner?
Yes . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . . . . . . . . . .[ ]
If yes,
2. How old is your partner?
number of years . . . . . . . . . . . . . ________
3. How old were you when you married or started living with
your partner?
number of years . . . . . . . . . . . . . ________
4. How long have you been married to (or living) with your
partner?
number of years . . . . . . . . . . . . . ._______
5. Did you ever see your mother hit your father?
Yes . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . . . . . . . . . .[ ]
6. Did you ever see your father hit your mother?
Yes . . . . . . . . . . . . . . . . . . . . . .[ ]
No. . . . . . . . . . . . . . . . . . . . . . .[ ]
Next: Appendix C
___________
Updates:
2001 02 10 (format changes)
2003 10 01 (format changes)
|
Male
and Female Perpetrated Partner Abuse