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Relationship Survey

Use the drop down arrow to select the response that best relates to your current situation.

What is your gender?
What is your age?
Where do you currently live?
Please estimate your annual household income ( US dollars).
Which of the following best describes your occupation?
What is your marital status?
How would you describe your current primary relationship?
How would you characterize your current primary relationship?
How would you describe your relationship with respect to making major decisions?
What action on your part do you believe would most help to improve your current relationship? (choose one)
What action on your signficant other's part do you believe would most help to improve your current relationship? (choose one)
For each of the following statements, use the criteria listed that best describes your current primary relationship.
Strongly Agree Agree Unsure Disagree Strongly Disagree
I love my significant other
I want to stay in a relationship with my current partner
I have adequate opportunity to personally grow and develop in my relationship
I am dependant upon my significant other for my happiness
I am afraid to be on my own
We have good times together often
We make a good couple
Our communication is effective
I am happy with the level of intimacy in my relationship
I am interested in having an affair outside of my relationship
Our sexual relationship is adequate
I am thinking about leaving the relationship
Choose the top 3 factors that you believe are critical to a happy loving relationship? (choose 3)
Sex Communication
Intimacy Mutual Interests
Time Together Family
Religion Independent Interests
Time Apart Fun
Spontenaity Financial Security
Children Stability
Similarities Differences
Physical Attractiveness Compassion
Understanding Other
How would you rate your level of satisfaction in your current relationship with respect to the following areas?
The Best Better Than Most Average Needs Improvement Unsure
Mutual Interests
Thank you for taking the time to complete this survey. Select Submit Survey now to send your responses to us.

This questionnaire was created by Perseus SurveySolutions for the Web.

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