Section 1

It seems as if my spouse needs a lot more than I do.

Things that are upsetting to my spouse seem like no big deal to me.

I don’t have many memories from my childhood.

I would describe myself as an independent, self-reliant person.

I would rather work on a project than sit and have a long conversation.

My spouse complains that I don’t show enough affection.

When something bad happens, I get over it and move on.

I need my space in relationships and feel annoyed if someone wants to be with me a lot.

I like to make decisions on my own.

I feel uncomfortable when someone is very emotional, especially if I think I am supposed to help.

In my family growing up, everyone sort of did their own thing.

I have siblings with whom I have little to no contact as an adult.

I have never felt particularly close to my parents.

Nothing gets me too bothered or upset.

I rarely cry.

Score:__________

Section 2

I am usually the giver in relationships.

I am good at keeping the peace.

I find I am able to anticipate the needs of my spouse and meet them.

Sometimes I am dishonest to avoid conflict.

I am afraid of making my spouse upset or angry.

When there is conflict, I’ll give in just to get it over with.

I don’t like to be alone.

It really upsets me when I feel someone is mad at me.

When someone requests my help, I have trouble saying no, so I sometimes find my self-overcommitted
and stressed.

I had a very critical (and/or angry) parent, and I tried very hard to win their approval.

Sometimes I get mad, but I usually don’t show it.

I am on the cautious side, and I wouldn’t call myself a risk taker.

I had an overprotective parent who worried a lot.

I had a parent that never stood up for himself or herself and passively accepted poor treatment.

When I sense others are distancing, I try harder to win them back.

Score:__________

Section 3

I feel like no one has ever really understood what I need.

I was instantly attracted to my spouse, and our early relationship was intense and passionate.

I hope for more in my relationships and am often disappointed as time moves on.

When my spouse tries, I feel it is too little, too late.

I am a very passionate person and feel things deeply.

I could describe many examples of how my spouse has hurt and disappointed me.

I can really sense when others pull away from me.

I want far more connection than I have in my marriage.

I like the feeling of making up after a fight.

When people hurt me long enough, I write them off.

If my spouse would pursue me a lot more, things would be better.

I don’t like to be alone, but when my spouse is around

I feel angry and empty.

My parent(s) still drives me crazy.

Sometimes I find myself picking fights, and I’m really not sure why.

I make it obvious when I’m hurt, and it makes it worse when my spouse does not pursue me and ask
what’s wrong.

It seems like I end up waiting for my partner to be available and pay attention to me.

Score:__________

Section 4

I grew up in a family with serious problems.

I have to keep my mate from knowing certain things because he or she would be angry.

I have a history of staying in (or being in) destructive relationships.

I suffer with depression and/or anxiety, and it makes it hard to cope.

Others say I’m in an abusive relationship, but I don’t think it’s that bad.

A lot of the time I feel like I’m checked out.

For most of my life I have felt unworthy and unlovable.

My parents had drug and alcohol problems.

One of my parents was abusive and the other passive.

I feel as if I functioned as the parent in my home growing up.

My spouse mistreats me, but I stay because it would be worse to be alone.

I was physically, emotionally, or sexually abused during my childhood or observed these things
happening to others.

I get nervous when things are calm because I know it won’t last and I’m waiting for my spouse to get
angry or critical.

Sometimes it feels as if life isn’t worth living.

I don’t let myself cry, because if I started, I’d never stop.

Score:_________
Section 5

Growing up, I had an angry parent (or sibling) who threatened me, intimidated me, and/or was violent
toward me.

No one protected me from harms way when I was growing up.

My spouse does things behind my back.

I feel angry when other people try to control me or tell me what to do.

I have problems with alcohol, drugs, pornography, gambling, or overspending.

My life is constant stress with one problem after another.

Sometimes I try to control my temper, but I feel too angry to stop.

My spouse does things that make me jealous.

I lose my temper a lot, especially at home, but my spouse (or kid) deserves it.

I have hit or pushed my spouse (or I have come very close).

I change jobs a lot.

By the time I was a teenager, people knew not to mess with me.

By the time I left home, some family members were afraid of me.

My spouse ignores me when I ask him or her to do things a certain way.

My spouse starts most of our fights because he or she doesn’t listen.

Score:__________