| 1. It’s okay with you when your partner spends time with friends or family. | _____No_____Yes_____Sometimes |
| 2. Your partner thinks it’s okay when you spend time with friends or family. | _____No_____Yes_____Sometimes |
| 3. Your partner likes the way you look & act and tells you so. | _____No_____Yes_____Sometimes |
| 4. You both decide how to spend your time together. | _____No_____Yes_____Sometimes |
| 5. Your partner has the power to make you feel bad - and uses it. | _____No_____Yes_____Sometimes |
| 6. Your partner pressures you to do things you don’t want to do. | _____No_____Yes_____Sometimes |
| 7. When you refuse to do certain things your partner puts you down. | _____No_____Yes_____Sometimes |
| 8. Your partner has threatened to hurt you or has hurt you. | _____No_____Yes_____Sometimes |
| 9. You feel full of happiness in this relationship. | _____No_____Yes_____Sometimes |
| 10. You are afraid of your partner’s temper, so you avoid making him/her angry. | _____No_____Yes_____Sometimes |
| 11. Your partner scares you by driving fast, drinking too much or doing other risky things. | _____No_____Yes_____Sometimes |
| 12. Your partner says, “I can’t live without you” and it scares you that it might comes true. | _____No_____Yes_____Sometimes |
| 13. You worry that the relationship might end and would do anything to keep it going. | _____No_____Yes_____Sometimes |
| 14. You think you can make your partner’s problems go away. | _____No_____Yes_____Sometimes |
| 15. Your partner believes that jealousy is a proof of love. | _____No_____Yes_____Sometimes |
| 16. You both agreed that you are a couple & trust each other to stick together. | _____No_____Yes_____Sometimes |
| 17. Your partner would always consider the risks regarding pregnancy or a sexually transmitted infection. | _____No_____Yes_____Sometimes |
| 18. You can be honest about your feelings and talk freely. | _____No_____Yes_____Sometimes |
