| 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. | _____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 be 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 |
Did you answer YES to questions 1, 2, 3, 4, 9, 16, 17, & 18?
If so, you are probably in a reasonably comfortable relationship.
If you answered YES or SOMETIMES to questions 5, 6, 7, 8, 10, 11, 12, 13, 14, and 15 you may be in an uncomfortable or even dangerous relationship. Trust your feelings; talk to someone.
To speak confidentially with a public health nurse at the
Simcoe Muskoka District Health Unit, call:
1-705-721-7520
or
Toll free 1-877-721-7520
Developed by City of Toronto Public Health
Modified by Simcoe Muskoka District Health Unit: August 2010
