Instructions: Answer every item true or false indicating the extent to which AT THIS TIME you
agree or disagree with each statement. You may want to print this page to make it easier to score.
Right now how do you feel?
I feel emotionally close to my partner.
2. I think that my partner really cares about me. True False
I feel confident that we can deal with
whatever problems or issues that might arise. True False
I would consider myself happy in this
relationship. True False
I feel respected by my partner. True False
I am committed to staying in this relationship. True False
I have a great deal of respect and admiration
for my partner. True False
I find my partner very interesting. True False
I feel that my partner finds me physically
attractive. True False
10. If I ever needed help I could count on my partner.
11. My partner really tries hard to meet my needs. True False
12. My partner really listens to me. True False
13. I am satisfied with our sex life. True False
14. I am confident we can handle any conflict that may arise between
us. True False
15. My partner shows pride in my accomplishments.
16. I feel appreciated for what I contribute to this relationship.
17. I really feel loved in this relationship.
18. My partner really knows me well.
19. My partner is one of my best friends.
20. My partner loves my sense of humor.