Couples Survey


Part 1












 


 

Part 2


Please rate yourself on the following items:




















































Part 3


Please indicate how you view your PARTNER on the following items:




















































Part 4


Sources of Relationship Irritation or Upset


Below is a list of things that partners sometimes do that irritate, annoy, anger, or upset each other. Indicate how much each of the following possible actions by your partner has upset you, in general, in the past year.

112. CONDESCENDING


For example, my partner placed more value on their own opinions, tried to act as if they were better than me, treated me like I was stupid or inferior, did things that made me feel inferior, or acted condescendingly toward me.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


113. POSSESSIVENESS - JEALOUSY


For example, my partner was too possessive of me, acted too dependent on me, demanded too much attention, demanded too much of my time, or acted jealous.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


114. NEGLECTING / REJECTING


For example, my partner was unreliable, would not spend enough time with me, did not tell me that they love me, ignored my feelings, or did not call when they said they would.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


115. PHYSICALLY ABUSIVE


For example, my partner physically hurt me (slapped me, hit me).

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


116. VERBALLY ABUSIVE


For example, my partner said things to intentionally hurt my feelings, called me nasty names, verbally abused me or insulted me.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


117. UNFAITHFUL


For example, my partner saw someone else intimately, had sex with someone else, wasn't faithful to me or lied to me about being with another person of the opposite sex.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


118. INCONSIDERATE


For example, my partner yelled at me, often left the toilet seat in the wrong position, often did not help clean up after themself, burped or belched loudly or didn't take my feelings into consideration.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


119. SELF-ABSORBED


For example, my partner focused too much with their appearance, talked to much or was self-absorbed.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


120. MOODY


For example, my partner was moody, had unpredictable mood swings, often seemed to have "the blues" or was irritable for no apparent reason.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


121. SEXUALLY WITHHOLDING / REJECTING


For example, my partner said "no" about having sex, told me they were not interested in my sexual advances, led me on and then turned me off or was a tease sexually.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


122. SEXUALIZED OTHERS


For example, my partner flirted with someone of the opposite sex, talked about how good-looking someone of the opposite sex was, idolized a member of the opposite sex who appeared on TV or talked about the opposite sex as if they were sex objects.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


123. ALCOHOL OR DRUG ABUSE


For example, my partner drank too much alcohol, got drunk, smoked too much or took illegal drugs.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


124. DISHEVELED


For example, my partner did not take care of their appearance, did not dress well or did not groom themselves well.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


125. INSULTING OF APPEARANCE


For example, my partner told me I was unattractive or ugly, told me that I looked fat or insulted something about my appearance.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


126. SEXUAL AGGRESSIVENESS


For example, my partner touched me sexually without my permission, used me for sexual purposes, tried to force sex acts on me or demanded sexual relations.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


127. SELF-CENTEREDNESS


For example, my partner was generally self-centered or acted selfishly.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


128. FINANCIALLY IRRESPONSIBLE


For example, my partner spent money unwisely, didn't consult me before making important purchases or spent too much money on frivolous things.

Overall, in the past year, how upset have you been by any of these behaviors of your partner?


Part 5


In the past year, indicate how much you and your partner tended to disagree about the following:

















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