• Most persons have disagreements in their relationships. Please indicate below the approximate extent of agreement or disagreement between you and your partner for each item on the following list.

  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree
  • Always AgreeAlmost Always AgreeOccasionally DisagreeFrequently DisagreeAlmost Always DisagreeAlways Disagree

  • All the timeMost of the timeMore often than notOccasionallyRarelyNever
  • All the timeMost of the timeMore often than notOccasionallyRarelyNever
  • All the timeMost of the timeMore often than notOccasionallyRarelyNever
  • All the timeMost of the timeMore often than notOccasionallyRarelyNever
  • All the timeMost of the timeMore often than notOccasionallyRarelyNever
  • All the timeMost of the timeMore often than notOccasionallyRarelyNever
  • All the timeMost of the timeMore often than notOccasionallyRarelyNever

  • Every DayAlmost Every DayOccasionallyRarelyNever

  • All of themMost of themSome of themVery few of themNone of them
  • How often would you say the following events occur between you and your mate?

  • NeverLess than once a monthOnce or twice a monthOnce or twice a weekOnce a dayMore often
  • NeverLess than once a monthOnce or twice a monthOnce or twice a weekOnce a dayMore often
  • NeverLess than once a monthOnce or twice a monthOnce or twice a weekOnce a dayMore often
  • NeverLess than once a monthOnce or twice a monthOnce or twice a weekOnce a dayMore often
  • NeverLess than once a monthOnce or twice a monthOnce or twice a weekOnce a dayMore often
  • These are some things about which couples sometimes agree and sometime disagree. Indicate if either item below caused differences of opinions or were problems in your relationship during the past few weeks. (Check yes or no)

  • YesNo
  • YesNo
  • Extremely UnhappyFairly UnhappyA Little UnhappyHappyVery HappyExtremely HappyPerfect
  • This field is for validation purposes and should be left unchanged.