|
Boolan (Yes/No)
|
Select
|
1
|
vb1
|
0
|
|
|
|
|
1. Within the past year, have you been hit, slapped, kicked or physically hurt by someone in any way?
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
2
|
vb2
|
0
|
|
|
|
|
2. Are you in a relationship with a person who physically hit you?
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
3
|
vb3
|
0
|
|
|
|
|
3. Are you in a relationship with a person who threatens, frightens or insults you or treats you badly?
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
4
|
vb4
|
0
|
|
|
|
|
4. Are you in relationship with a person who forces you to participate in sexual activities that make you feel uncomfortable?
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
5
|
vb5
|
0
|
|
|
|
|
5. Have you ever experienced any of the above with someone you do not have a relationship with?
|
|
|
|
| | | |
|
Boolan (Yes/No)
|
Select
|
6
|
vb6
|
0
|
|
|
|
|
Did the patient seek help after experiencing GBV?
|
|
|
|
| | | |
|
String
|
Select
|
7
|
vt1
|
0
|
|
|
|
|
from who ?
|
|
|
|
| | | |
|
Datetime
|
Date Picker
|
8
|
vd1
|
0
|
|
|
|
|
Date when the patient sought help
|
|
|
|
| | | |
|
String
|
Select
|
9
|
vt2
|
0
|
|
|
|
|
Outcome after seeking help
|
|
|
|
| | | |
|
String
|
Text box
|
10
|
vt3
|
0
|
|
|
|
|
Reason for not seeking help
|
|
|
|
| | | |
