1. What do you feel when you remember the good old days?
A. I feel warm and fuzzy
B. I feel nostalgic
C. I feel bitter
D. I feel angry for being such a fool once
2. What is the most important value for you?
A. Family
B. Romantic love
C. Being happy about myself
D. Money and career
3. Do you two go on dates?
A. Yes, as often as we can
B. Sometimes
C. Rarely
D. Never
4. Do you share your emotions with your spouse?
A. Yes, it makes me feel safe and comfortable
B. Sometimes
C. Rarely
D. Never
5. Do you still want to have sex with your spouse?
A. Yes, absolutely
B. Yes, but the conflicts between us prevent me from doing so
C. Sometimes
D. No, not at all
6. Do you still respect each other?
A. Yes
B. Less than before
C. Not really
D. Not at all
7. Is there any affair involved in your bad situation?
A. No, we haven't cheated on each other
B. Yes, emotional cheating
C. Yes, but it's over
D. Yes, and the cheater doesn't want to put an end to it
8. Do you fantasize about life without your spouse?
A. No, I can't imagine my life without him or her
B. Sometimes
C. Often
D. Yes, this is all I want from life
9. Has any form of physical abuse taken place in your marriage?
A. No, not at all
B. No, but we were close
C. Yes, minor
D. Yes, serious
10. Do any of you have a substance abuse problem?
A. No
B. No, not at this moment
C. Yes, but he or she is getting help
D. Yes, and he or she is not getting help
