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.
Please answer using the following:
(1) Strongly Disagree (2) Somewhat Disagree (3) Somewhat Agree (4) Strongly Agree
Full Name * 1. Handling family finances * 2. Matters of recreation * 3. Religious matters * 4. Demonstrations of affection * 5. Friends * 6. Sex relations * 7. Conventionality (correct or proper behavior) * 8. Philosophy of Life * 9. Ways of dealing with parents or in-laws * 10. Aims, goals and things believed important * 11. Amount of time spent together * 12. Making major decisions * 13. Household tasks * 14. Leisure time interests and activities * 15. Career decisions *
16. How often do you discuss or have you considered divorce, separation or terminating your relationship? * 17. How often do you or your mate leave the house after a fight? * 18. In general, how often do you think that things between you and your partner are going well? * 19. Do you confide in your mate? * 20. Do you ever regret that you married? (or lived together) * 21. How often do you and your partner quarrel? * 22. How often do you and your mate “get on each other’s nerves?” *
23. Do you kiss your mate? *
24. Do you and your mate engage in outside interests together? *
How often would you say the following events occur between you and your mate?
25. Have a stimulating exchange of ideas * 26. Laugh together * 27. Calmly discuss something * 28. Work together on a project * 28. Work together on a project *
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)
29. Being too tired for sex * 30. Not showing love * 31. The circles on the following line represent different degrees of happiness in your relationship. The
middle point, “happy,” represents the degree of happiness of most relationships. Please fill in the circle
which best describes the degree of happiness, all things considered, of your relationship. * 32. Which of the following statements best describes how you feel about the future of your relationship? * Name
This field is for validation purposes and should be left unchanged.