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Dear Sir or Madam, please take a few minutes of your time to complete the following questionnaire.
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1
How often do you communicate with your partner?
Choose the option that best represents your situation.
Daily
Weekly
Monthly
Rarely
2
Rate the support you receive from your friends and family for your relationship (1 to 10).
Rate the level of support from 1 being the lowest to 10 being the highest.
3
Describe a recent conflict in your relationship.
Please provide a detailed answer explaining the conflict.
4
How do you express love to your partner?
Choose the ways you most commonly express love.
Words of Affirmation
Quality Time
Acts of Service
Physical Touch
Gifts
5
On a scale of 1 to 5, how well do you feel understood by your partner?
Rate the level of understanding from 1 being the lowest to 5 being the highest.
6
What is the biggest challenge you face in your current relationship?
Please describe the main challenge you are dealing with.
7
Do you feel respected in your relationship?
Choose the option that best reflects your feelings.
Yes
No
Sometimes
8
How do you handle disagreements with your partner?
Select the approach you usually take when facing disagreements.
Communicate openly
Avoid confrontation
Seek compromise
Take time to cool off
9
What qualities do you appreciate the most in your partner?
Select the qualities that are most valuable to you.
Honesty
Compassion
Sense of humor
Trustworthiness
Supportiveness
10
How satisfied are you with the overall health of your relationship?
Rate your satisfaction level from 1 being the lowest to 10 being the highest.
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