Couple's Relationship Health Questionnaire

Couple's Relationship Health Questionnaire

Questionnaire designed for couples to assess their relationship’s intimacy, communication skills, values alignment, love languages, and overall strength.
Name*

First NameLast Name
Email*
example@example.com
Section 1: Intimacy
Emotional Intimacy: How often do you feel emotionally connected to your partner?

RarelySometimesOftenAlways
Emotional Intimacy: How comfortable are you sharing your innermost thoughts and feelings with your partner?

Not comfortableSomewhat comfortableVery comfortableCompletely comfortable
Emotional Intimacy: Do you feel that your partner understands your emotions and supports you during difficult times?

RarelySometimesOftenAlways
Physical Intimacy: How satisfied are you with the level of physical affection in your relationship? (Hugs, cuddles, kisses, etc.)

Not satisfiedSomewhat satisfiedVery satisfiedCompletely satisfied
Physical Intimacy: How often do you and your partner engage in physical intimacy (including sexual connection)?

RarelySometimesOftenVery often
Section 2: Communication Skills
Active Listening: How often do you feel that your partner listens to you without interrupting or judging?

RarelySometimesOftenAlways
Active Listening: Do you feel comfortable voicing your needs, thoughts, and concerns in your relationship?

Not comfortableSomewhat comfortableVery comfortableCompletely comfortable
Conflict Resolution: How well do you and your partner resolve conflicts or disagreements?

We struggle to resolve conflictsWe sometimes resolve conflicts but avoid difficult topicsWe resolve conflicts with effort and patienceWe resolve conflicts openly and constructively
Conflict Resolution: How often do conflicts result in either person feeling hurt or misunderstood?

Very oftenSometimesRarelyNever
Non-Verbal Communication: How attuned are you to your partner’s non-verbal cues (e.g., body language, facial expressions)?

Not attunedSomewhat attunedVery attunedExtremely attuned
Non-Verbal Communication: Do you feel that your partner is responsive to your non-verbal signals (e.g., gestures,mood changes)?

Not at allSomewhat responsiveVery responsiveExtremely responsive
Values Alignment
Shared Life Goals: How aligned do you and your partner feel about your long-term life goals (e.g., career, family, lifestyle)?

Not alignedSomewhat alignedMostly alignedCompletely aligned
Personal Values: How often do you and your partner discuss your personal values and how they shape your decisions?

RarelySometimesOftenVery often
Personal Values: How much do your core personal values overlap with your partner’s values?

Not at allSlightlyModeratelyCompletely
Daily Living and Shared Decisions: How aligned are you and your partner in daily decision-making (e.g., finances, household responsibilities)?

Not alignedSomewhat alignedMostly alignedCompletely aligned
Love Languages
Understanding Each Other's Love Language: How well do you understand your partner’s primary love language (e.g., words of affirmation, acts of service, physical touch, quality time, receiving gifts)?

Not wellSomewhat wellVery wellCompletely well
Understanding Each Other's Love Language: How often do you consciously express love to your partner in their preferred love language?

RarelySometimesOftenAlways
Feeling Loved: How often do you feel loved and appreciated by your partner in the way you prefer toreceive love?

RarelySometimesOftenAlways
Feeling Loved: How important is it to you that your partner expresses love in your preferred love language?

Not importantSomewhat importantVery importantExtremely important
Strength of Relationship
Trust and Emotional Security: How much do you trust your partner to be honest and loyal in your relationship?

Not at allSlightlyMostlyCompletely
Trust and Emotional Security: How emotionally secure do you feel in your relationship?

Not secureSomewhat secureVery secureCompletely secure
Support and Partnership: How well does your partner support you during difficult times (emotionally, mentally, or physically)?

Not wellSomewhat wellVery wellExtremely well
Support and Partnership: How satisfied are you with the balance of partnership (e.g., shared responsibilities,mutual support) in your relationship?

Not satisfiedSomewhat satisfiedVery satisfiedCompletely satisfied
Relationship Strength: How would you rate the overall strength of your relationship?

Weak and strugglingSomewhat strong but needs workStrong with room for growthVery strong and thriving
What do you believe is the greatest strength of your relationship?
What is the biggest challenge you and your partner face in yourrelationship?
If you could change one thing in your relationship, what would it be?
What would you most like to work on together as a couple?
Total *
Interpretation of Scores:
- 90 - 112: Relationship is thriving with strong intimacy, communication, and
  alignment.
- 70 - 89: Relationship is strong but could benefit from specific areas of growth.
- 50 - 69: Relationship is stable but requires attention in several key areas.
- Below 50: Relationship may be struggling and could greatly benefit from
  coaching.
This scoring system allows for an objective assessment based on the couple's
responses while leaving room for open-ended exploration and tailored
recommendations.

If you are interested in cultivating more intimacy, love and connection in your relationship, feel free to reach out to Michael for a discovery call to see if you are a right fit for his couples program
https://calendly.com/ michaeldostrolenk/30-minute- coaching-with-mo-clone
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Couple's Relationship Health Questionnaire

Section 1: Intimacy

Section 2: Communication Skills

Values Alignment

Love Languages

Strength of Relationship