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How Healthy is Your Relationship
1
Name
First Name
Last Name
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2
Email
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3
1.
I feel physically safe with my partner:
Never
Sometimes
Often
Always
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4
2.
My partner feels physically safe with me:
Never
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5
3.
My emotional needs are met by my partner:
Never
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Often
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6
4.
My physical needs (eg. food, shelter, clothing etc.) are met by my partner:
Never
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7
5.
My sexual needs are met by my partner:
Never
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Always
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8
6.
My partner and I work well as a team:
Never
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Always
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9
7.
My partner knows what I need when I’m stressed:
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10
8.
My partner is good at communicating in my love language:
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11
9.
I respect my partner:
Never
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12
10.
I appreciate my partner:
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13
11.
My partner respects me:
Never
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Always
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14
12.
My partner appreciates me:
Never
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15
13.
I need my partner:
Never
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Always
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16
14.
My partner needs me:
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17
15.
I feel seen, heard and understood by my partner:
Never
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18
16.
My partner feels seen, heard and understood by me:
Never
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19
17.
We have many common interests and hobbies:
Never
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20
18.
I meet my partner's emotional needs:
Never
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Often
Always
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21
19.
I meet my partner's physical needs (eg. food, shelter, clothing etc.):
Never
Sometimes
Often
Always
Unsure
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22
20.
I meet my partner's sexual needs:
Never
Sometimes
Often
Always
Unsure
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23
21.
My partner and I are good at communicating:
Never
Sometimes
Often
Always
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24
22.
My partner and I are good at resolving conflict:
Never
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Always
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25
23.
My partner and I share common goals for the future:
Never
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Always
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26
24.
My partner and I share common values:
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Always
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27
25.
Even though things are sometimes challenging, I know I want to be with my partner long term:
Never
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Always
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28
Calculation
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