Love Kindlers Questionnaire
Copyright © 2010 by Cindy J. Taylor
Date
January
February
March
April
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June
July
August
September
October
November
December
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Day
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Year
Full Name
First Name
Last Name
E-mail (we'll send you a copy of your responses)
Emotional Commitment
A. LOVED--Do you feel a loving emotional connection and commitment from your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
B. VALUED--Do you believe you are valued by your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
C. RESPECTED--Do you believe your spouse respects you?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
D. TRUSTED--Does your spouse trust you and see you as trustworthy?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
E. ACCEPTED--Are you accepted for the person you are by your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
F. APPRECIATED--Does your spouse express appreciation for you and the things you do?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
G. AFFECTION--Is affection for you expressed in words and actions?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
H. ADMIRED--Do you believe your spouse admires you and do they say so out loud?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
I. UNDERSTOOD--Do you believe you are heard and understood by your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
J. FORGIVENESS--When you do something wrong does your spouse forgive you and not bring it up later in an argument?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Spiritual Commitment
A. Are your spiritual values supported by your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
B. Do you and your spouse have a shared spiritual life?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
C. Are your beliefs respected?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
D. Is there personal transparency about your spiritual beliefs?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Physical Commitment
A. TOUCHED--Are you regularly touched by your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
B. Are you touched in ways that you like?
Yes
Sometimes
No
C. KISSED--Are you regularly kissed by your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
D. KISSED--Are you kissed in a way and as long as you like?
Yes
Sometimes
No
E. HUGGED--Are you regularly hugged by your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
F. HUGGED--Are you hugged in a way that you like?
Yes
Sometimes
No
G. TENDERNESS--Does your spouse regularly express physical tenderness (for example cuddling, holding hands, etc.)?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
H. TENDERNESS--Is the physical tenderness in a way that you like?
Yes
Sometimes
No
I. SEXUAL FULFILLMENT--Are you and your spouse regularly sexually active so that you are satisfied?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Is the sexual activity in your marriage the way that you like?
Yes
Sometimes
No
PHYSICAL ATTRACTIVENESS--Are you physically attracted to your spouse (their hair, their body, their grooming and their clothing)?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Financial Commitment
A. Is your spouse able to provide for family and children?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
B. Does your spouse actively participate in providing for family and children?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
C. Are you able to pay monthly bills without going into debt?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
D. Can you live a lifestyle that's mutually acceptable to both you and your spouse?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
E. Does your spouse contribute to family income?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
F. Does your spouse contribute to paying off family debt?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
G. Are you able to plan for future financial stability?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
H. Are you able to plan for future needs such as kids' college?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
I. Can your spouse live by a budget?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Family Commitment
A. Does your spouse make time for adult time alone with you?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
B. Does your spouse make time for the children, individually?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
C. Does your spouse share household chores in a way that seems equitable to you?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
D. Does your spouse share child rearing?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
E. Does your spouse say 'yes' more than 'no' whenever it's possible?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
F. Does your spouse offer you 'a day off' now and then?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Social Commitment
A. Are you included in your spouse's social activities?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
B. Does your spouse encourage and support you in social situations?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
C. Do you and your spouse share fun and enjoyable activities together?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
D. Do you and your spouse share joy and laughter?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
E. As you believe it's appropriate, do you and your spouse publicly display affection for each other?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
F. Does your spouse spend their free time with you?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
G. Does your spouse offer you personal free time?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
H. Is your spouse your companion?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
I. Does your spouse engage you in conversation, about topics in which you both have an interest?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
J. Does your spouse listen well, expressing both interest and caring?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Security Commitment
A. Does your spouse support you in times of crisis?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
B. Does your spouse turn to you for support in their times of crisis?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
C. Does your spouse stand by you?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
D. Is your spouse loyal and committed to you and your marriage?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
E. Does your spouse present a united front with you (against relatives or the children)?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
F. Is your relationship secure and not “in the balance” over a fight?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
G. Is your spouse there for you when you feel you need them?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
H. Is your spouse your "soft place to fall" (a safe haven)?
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Submit
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