Instructions: Choose the answer for each question that best corresponds to the most accurate response for how you've acted or feel.

 

1. I told my partner that I loved him/her today.

Yes
No

2. I listened to my partner when they needed someone to listen to them in the past week.

Yes, nearly all the time
Sometimes
No, barely at all

3. When my partner asked me to do something this past week, I gladly did it without giving her/him a hard time.

Yes
No

4. My partner and I talked about something important to the both of us in the past week.

Yes, it was important to both of us
Yes, but it was more important to one of us
No

5. My partner and I argued about something this past week.

Yes
No

6. What we argued about was very important to the future of our relationship or our lives

Yes, it was very important to both of us
Yes, but it was only mildly important to one of us
No, it wasn't important
We didn't argue

7. I feel sexually attracted to my partner.

Not at all
Just a little
Somewhat
Quite a lot
Very much

8. I find myself agitated and annoyed by my partner during the past week.

Not at all
Just a little
Somewhat
Quite a lot
Very much

9. I feel overwhelmed by my partners needs or feelings.

Not at all
Just a little
Somewhat
Quite a lot
Very much

10. I did something nice and unexpected for my partner this past week.

Yes
No

11. My partner did something nice and unexpected for me this past week.

Yes
No

12. I feel like a failure around my partner this past week.

Not at all
Just a little
Somewhat
Quite a lot
Very much

13. I look forward to the future together with my partner.

Not at all
Just a little
Somewhat
Quite a lot
Very much

14. My sleep has been disturbed -- too little, too much, or broken sleep.

Not at all
Just a little
Somewhat
Quite a lot
Very much

15. I spent time thinking about what life would be without my partner this past week.

Yes
No

16. I feel trapped or caught in my relationship.

Not at all
Just a little
Somewhat
Quite a lot
Very much

17. I do not feel happy or hopeful even when good things happen to me.

Not at all
Just a little
Somewhat
Quite a lot
Very much

18. I feel very close to my partner.

Not at all
Just a little
Somewhat
Quite a lot
Very much

 

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Last reviewed:
  On 4 Dec 2007
  By John M. Grohol, Psy.D.