Circle the response choice that best reflects how you feel now concerning each area of your relationship. Try not to allow one category to influence the results of the other category.
| QUESTIONS | STRONGLY HAPPY | HAPPY | NEUTRAL (UNDECIDED) | UNHAPPY | STRONGLY UNHAPPY |
|---|---|---|---|---|---|
| How happy am I in the following areas of my relationship? | |||||
| •Roles, gender roles, division of household responsibilities | 1 | 2 | 3 | 4 | 5 |
| •Time spent together, including leisure time | 1 | 2 | 3 | 4 | 5 |
| •Money, financial position, financial decisions | 1 | 2 | 3 | 4 | 5 |
| •Communication | 1 | 2 | 3 | 4 | 5 |
| •Affection and sex | 1 | 2 | 3 | 4 | 5 |
| •Religious beliefs, values, and practice | 1 | 2 | 3 | 4 | 5 |
| •Decision making | 1 | 2 | 3 | 4 | 5 |
| •Conflict resolution | 1 | 2 | 3 | 4 | 5 |
| •The way we deal with anger | 1 | 2 | 3 | 4 | 5 |
| •Social activities and relationships with friends | 1 | 2 | 3 | 4 | 5 |
| How happy am I with the following areas in my own life? | |||||
| •Personal independence | 1 | 2 | 3 | 4 | 5 |
| •Academic (or occupational) progress | 1 | 2 | 3 | 4 | 5 |
| •Self-worth | 1 | 2 | 3 | 4 | 5 |
| •Relationship with my parents and family | 1 | 2 | 3 | 4 | 5 |
| •Relationship with my in-laws and their family | 1 | 2 | 3 | 4 | 5 |
| Overall, how happy am I within my relationship? | 1 | 2 | 3 | 4 | 5 |
Adapted from Poon.5