Relationship Survey

Section A
1. I feel like I always do everything for my partner and he/she never does  True  False
anything for me.
2. I can see how I am always being hurt by my partner.  True  False
3. It doesn’t always occur to me to consider my partner’s feelings.  True  False
4. I meet my own needs because my partner often doesn’t meet them.  True  False
5. I’m reluctant to yield to my partner’s opinions/requests.  True  False
6. I no longer try to find ways to meet my partner’s needs.  True  False

Section B
7. During problem discussions, my stomach often feels as if it is all tied up  True  False
in knots.
8. I would describe myself as very emotionally charged or tense whenever  True  False
there is a major disagreement.
9. My body often becomes tense during a relationship problem discussion.  True  False
10. I often feel a lump in my throat when I argue with my partner.  True  False
11. My heart often speeds up or races during our conversations.  True  False
12. I often feel very anxious at the start of problem discussions.  True  False

Section C
13. My partner does not try very hard to understand me.  True  False
14. I don’t feel safe in the relationship if I don’t have answers to the  True  False
problems we’re experiencing as a couple.
15. When my partner does something that makes me angry, I usually let  True  False
him/her know about it.
16. I really need to talk about my feelings or problems in the relationship in  True  False
order to feel better about them.
17. I often push my partner to talk about issues even when it is clear that  True  False
my he/she doesn’t want to talk
18. I feel good after getting angry.  True  False
19. I tend to give advice when I’m not asked.  True  False
20. If my partner will not talk to me about a particular issue, I often get  True  False
louder with my demands.
21. I sometimes nag at my partner in order to get back at him/her.  True  False
22. It is very easy for me to get angry at my partner.  True  False

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© 2010 – 2011 Townsend Relationship Center. All Rights Reserved. Do not duplicate or distribute without permission.
Section D
23. Sometimes I don’t talk to my partner because I’ve noticed that talking  True  False
leads to fighting.
24. When my partner and I disagree, he/she is always so negative, loud, or  True  False
demanding.
25. I often find myself saying, “I don’t care, whatever you want is fine with  True  False
me” when I’m asked for an opinion.
26. If I had my choice I would avoid conflicts and disagreements.  True  False
27. I just want peace and wonder at times why my partner won’t ever just be  True  False
quiet.
28. When my partner brings up a relationship issue, I tend to withdraw,  True  False
become silent, or refuse to discuss the matter further.
29. I often agree with my partner’s wishes just to end the discussions.  True  False
30. It doesn’t matter what I say, it’s never right.  True  False
31. I often sit and stare at my partner, not saying anything.  True  False
32. It is easier for me to do what my partner wishes or leave the room rather  True  False
than force my way on him/her.

Section E
33. We hardly ever do any fun things together.  True  False
34. I frequently don’t have confidence in or trust my partner’s abilities or  True  False
motives.
35. I am basically unhappy with my relationship.  True  False
36. I often don’t feel close to my partner.  True  False
37. I am not satisfied with our sex life.  True  False
38. Most of the time I do not feel supported by my partner.  True  False

Section F
39. I have little confidence in being able to discuss a significant relationship  True  False
problem with my partner without fighting.
40. In five out of ten disagreements with my partner, I will be unable to  True  False
make any headway in reaching a happy solution.
41. I am devastated because I had so many dreams and hopes for our  True  False
future and it feels like none of them will ever be possible anymore.
42. Sometimes I feel like we’re trapped in a cycle of endless blame, anger,  True  False
and shame.
43. Since I can’t talk to my partner anymore, I have a friend that I talk to  True  False
about my problems—someone who understands me.
44. At times I don’t feel like staying with my partner anymore and am  True  False
wondering if there’s any reason why I should.
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© 2010 – 2011 Townsend Relationship Center. All Rights Reserved. Do not duplicate or distribute without permission.
Section G
45. I’ve said to myself regularly, “I deserve better than this.”  True  False
46. I have actually researched getting a divorce.  True  False
47. I have begun thinking about how things could be different/better for me  True  False
without my partner.
48. I have thought about and brought up the word “divorce” with my partner.  True  False
49. If things don’t work out with my partner, I have a plan in place to move  True  False
forward without her/him.
50. The fact that we could be considering getting divorced is out in the open  True  False
now with family and friends

Results
Now go through each section above and tally up your scores of the number of True and False answers from each section

Section A – Selfishness True____________ False____________

Questions 1 – 6

Section B – Reactivity True____________ False____________

Questions 7 – 12

Section C – Polarization/Pursuer True____________ False____________

Questions 13 – 22

Section D – Polarization/Withdrawer True____________ False____________

Questions 23 – 32

Section E – Negative Interpretation True____________ False____________

Questions 33 – 38

Section F – Hopelessness True____________ False____________

Questions 39 – 44

Section G – Abandonment True____________ False____________

Questions 45 – 50

Get video instructions for this worksheets at www.StarvedMarriage.com as well as other free resources for making your relationship rock.
© 2010 – 2011 Townsend Relationship Center. All Rights Reserved. Do not duplicate or distribute without permission.
Get video instructions for this worksheets at www.StarvedMarriage.com as well as other free resources for making your relationship rock.
© 2010 – 2011 Townsend Relationship Center. All Rights Reserved. Do not duplicate or distribute without permission.