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Form Id: FRM_GBV_SCR

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1. Within the past year, have you been hit, slapped, kicked or physically hurt by someone in any way?:	YesNo
State the perpetrator:	Sexual PartnerBoyfriendRelativeOther (Specify)
Specify who (if other was previously selected):
2. Are you in a relationship with a person who physically hit you?:	YesNo
State the perpetrator:	Sexual PartnerBoyfriendRelativeOther (Specify)
Specify who (if other was previously selected):
3. Are you in a relationship with a person who threatens, frightens or insults you or treats you badly?:	YesNo
State the perpetrator:	Sexual PartnerBoyfriendRelativeOther (Specify)
Specify who (if other was previously selected):
4. Are you in relationship with a person who forces you to participate in sexual activities that make you feel uncomfortable?:	YesNo
State the perpetrator:	Sexual PartnerBoyfriendRelativeOther (Specify)
Specify who (if other was previously selected):
5. Have you ever experienced any of the above with someone you do not have a relationship with?:	YesNo
State the perpetrator:	Sexual PartnerBoyfriendRelativeOther (Specify)
Specify who (if other was previously selected):
Did the patient seek help after experiencing GBV?:	YesNo
from who ?:	HospitalPolice,Peer educatorFamilyPeers
Date when the patient sought help:
Outcome after seeking help:	No action takenCounsellingEmergency pillsHiv testingInvestigation doneMatter presented to courtP3 form issuedPEP givenPerpetrator arrestedPost rape carePrEP givenReconciliationReferred back to the familyReferred to hospitalStatement takenSTI ProphylaxisTrauma counselling doneTreatmentOther (specify)
Reason for not seeking help:

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