Couples Survey

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Couples Survey

To determine if you and your partner is in a healthy relationship

Page 1

Question 1*

Who is filling out this form?

Her

Him

Question 2*

Your Age

Question 3*

Your partner's age

Question 4*

Your Annual Income

Question 5*

Your Partner's Annual Income

Question 6*

Your Highest Level of Education

Question 7*

Partner's Highest Level of Education

Question 8*

What is your relationship status?

Married

Not Married

Question 9*

How many years have you been together?

Less than a year

1-3 years

3-5 years

5-10 years

10-20 years

20 or more years

Question 10*

How satisfied are you with your partners emotional support?

Question 11*

How satisfied you are with the respect and admiration received from your partner?

Question 12*

How satisfied are you with your partners financial support?

Question 13*

How satisfied are you with your sex life?

Question 14*

How satisfied are you with the time you spend together with your partner?

Question 15*

How often do you argue about the following reasons?

Question 16*

How fast are your relationship issues resolved or forgiven?

Immediately

Next Day

At least a week

Always hold a grudge

Question 17*

From 1 to 10 how would you rate your relationship?

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