Love Kindlers Questionnaire Form

Date

Month Day Year

Full Name

First Name Last Name

E-mail (we'll send you a copy of your responses)

A. LOVED--Do you feel a loving emotional connection and commitment from your spouse?

	1	2	3	4	5

1 is Worst, 5 is Best

B. VALUED--Do you believe you are valued by your spouse?

	1	2	3	4	5

1 is Worst, 5 is Best

C. RESPECTED--Do you believe your spouse respects you?

	1	2	3	4	5

1 is Worst, 5 is Best

D. TRUSTED--Does your spouse trust you and see you as trustworthy?

	1	2	3	4	5

1 is Worst, 5 is Best

E. ACCEPTED--Are you accepted for the person you are by your spouse?

	1	2	3	4	5

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

1 is Worst, 5 is Best

G. AFFECTION--Is affection for you expressed in words and actions?

	1	2	3	4	5

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

1 is Worst, 5 is Best

I. UNDERSTOOD--Do you believe you are heard and understood by your spouse?

	1	2	3	4	5

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

1 is Worst, 5 is Best

A. Are your spiritual values supported by your spouse?

	1	2	3	4	5

1 is Worst, 5 is Best

B. Do you and your spouse have a shared spiritual life?

	1	2	3	4	5

1 is Worst, 5 is Best

C. Are your beliefs respected?

	1	2	3	4	5

1 is Worst, 5 is Best

D. Is there personal transparency about your spiritual beliefs?

	1	2	3	4	5

1 is Worst, 5 is Best

A. TOUCHED--Are you regularly touched by your spouse?

	1	2	3	4	5

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

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

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

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

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

1 is Worst, 5 is Best

A. Is your spouse able to provide for family and children?

	1	2	3	4	5

1 is Worst, 5 is Best

B. Does your spouse actively participate in providing for family and children?

	1	2	3	4	5

1 is Worst, 5 is Best

C. Are you able to pay monthly bills without going into debt?

	1	2	3	4	5

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

1 is Worst, 5 is Best

E. Does your spouse contribute to family income?

	1	2	3	4	5

1 is Worst, 5 is Best

F. Does your spouse contribute to paying off family debt?

	1	2	3	4	5

1 is Worst, 5 is Best

G. Are you able to plan for future financial stability?

	1	2	3	4	5

1 is Worst, 5 is Best

H. Are you able to plan for future needs such as kids' college?

	1	2	3	4	5

1 is Worst, 5 is Best

I. Can your spouse live by a budget?

	1	2	3	4	5

1 is Worst, 5 is Best

A. Does your spouse make time for adult time alone with you?

	1	2	3	4	5

1 is Worst, 5 is Best

B. Does your spouse make time for the children, individually?

	1	2	3	4	5

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

1 is Worst, 5 is Best

D. Does your spouse share child rearing?

	1	2	3	4	5

1 is Worst, 5 is Best

E. Does your spouse say 'yes' more than 'no' whenever it's possible?

	1	2	3	4	5

1 is Worst, 5 is Best

F. Does your spouse offer you 'a day off' now and then?

	1	2	3	4	5

1 is Worst, 5 is Best

A. Are you included in your spouse's social activities?

	1	2	3	4	5

1 is Worst, 5 is Best

B. Does your spouse encourage and support you in social situations?

	1	2	3	4	5

1 is Worst, 5 is Best

C. Do you and your spouse share fun and enjoyable activities together?

	1	2	3	4	5

1 is Worst, 5 is Best

D. Do you and your spouse share joy and laughter?

	1	2	3	4	5

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

1 is Worst, 5 is Best

F. Does your spouse spend their free time with you?

	1	2	3	4	5

1 is Worst, 5 is Best

G. Does your spouse offer you personal free time?

	1	2	3	4	5

1 is Worst, 5 is Best

H. Is your spouse your companion?

	1	2	3	4	5

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

1 is Worst, 5 is Best

J. Does your spouse listen well, expressing both interest and caring?

	1	2	3	4	5

1 is Worst, 5 is Best

A. Does your spouse support you in times of crisis?

	1	2	3	4	5

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

1 is Worst, 5 is Best

C. Does your spouse stand by you?

	1	2	3	4	5

1 is Worst, 5 is Best

D. Is your spouse loyal and committed to you and your marriage?

	1	2	3	4	5

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

1 is Worst, 5 is Best

F. Is your relationship secure and not “in the balance” over a fight?

	1	2	3	4	5

1 is Worst, 5 is Best

G. Is your spouse there for you when you feel you need them?

	1	2	3	4	5

1 is Worst, 5 is Best

H. Is your spouse your "soft place to fall" (a safe haven)?

	1	2	3	4	5

1 is Worst, 5 is Best

Love Kindlers Questionnaire

Emotional Commitment

Spiritual Commitment

Physical Commitment

Financial Commitment

Family Commitment

Social Commitment

Security Commitment