I've started modifying and adding questions to the Felitti form. My intent is to create a digital format that can be answered in the office or waiting room, but eventually add in some automated responses to some of the answers. If someone responded with a significant history of abuse, the system might be prompted to "I'm sorry those things happened to you. They should not have happened and it is not your fault that you were hurt. But I'm glad you shared that with me. It helps me to know more about you. IT may not make sense to you now, but having these experiences can change the way your mind and body work together. I'll explain this more to you when I see you.
I've also used a folded sheet of paper in an envelope with colored circular stickers on it. The questions are very non-threateneing and do not use the words "violence" or "Abuse." The patient simply moves the color of sticker that fits their scenario best - green, yellow, or blue. There are categories of statements and the patient is asked to decide which set of statements most closely fits them. They move the colored stickers, give it back to the nurse in the envelope for the provider to see and decide about appropriate next steps and followup. I'm attaching the one that specifically deals with screening for domestic violence, but it can be modified many ways. It is gender neutral and relationship neutral.
Dave McCollum