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  1. Surveys
  2. 2015
  3. November
  4. M
  5. Marital Satisfaction Questionnaire
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Exit Survey
 
 
Please list three things you would like your partner to do more often. Put an X under the days, indicating how often he/she did each of these things during the past seven days.
   
 
 
 
List Three Things you think your partner would like you to do for him/her and put an X under the days indicating how often you did each of these things during the past seven days.
   
 
 
 
In what ways have I been showing or giving love lately?
   
 
 
 
Overall, on a scale of 0-10, (0=very dissatisfied and 10= very satisfied), rate the following (circle a number):
   
 
   
How satisfied do you think your partner is with your relationship?
   
0 1 2 3 4 5 6 7 8 9 10
   
 
   
How satisfied are you with you relationship?
   
0 1 2 3 4 5 6 7 8 9 10
   
 
 
 
List three things which you believe would improve your satisfaction with your relationship.
   
 
 
 
List three things which you believe would improve your partner’s satisfaction with your relationship.
   
 
 
 
Overall, on a scale of 0-10 (0=not at all committed and 10=very committed), rate the following (circle a number):
   
1. How committed do you think your partner is to working on this relationship?
   
2. How committed are you to working on this relationship?
   
 
   
3. How committed do you think your partner is to making changes to improve the relationship?
   
4. How committed are you to making changes to improve the relationship?