Marital Health CheckΔMARITAL HEALTH CHECKFirst NameLast NameGender Female MaleDate of Birth (mm/dd)Year of Birth EmailPhoneProfessionBirth Order (E.g 1st out of Five, 2/5, 3/5, 5/5...)For how long have you been married?State briefly why you married your spouseSection 1 - PERSONALITY PROFILERead the list of statements and rate yourself from 0 - 10, with zero being the statement that least describes you and ten being the statement that most describes you.1. Many people think I am unemotional and blunt in relating with people and handling issues. 0 1 2 3 4 5 6 7 8 9 102. My work rate is high, able to work under pressure, taking risks or projects others think can’t be done. 0 1 2 3 4 5 6 7 8 9 103. I easily take the lead wherever I find myself and could get upset when goals are not met. 0 1 2 3 4 5 6 7 8 9 104. I usually ignore how people feel when I am chasing a goal or trying to get results. 0 1 2 3 4 5 6 7 8 9 105. I am very opinionated, and I can make decisions for others easily. 0 1 2 3 4 5 6 7 8 9 106. I love people and always want to make them happy. 0 1 2 3 4 5 6 7 8 9 107. I encourage people to work together and easily let go offences so we can move on 0 1 2 3 4 5 6 7 8 9 108. People notice me easily and love me because I am the life of the party wherever I find myself 0 1 2 3 4 5 6 7 8 9 109. I can motivate people to get things done. 0 1 2 3 4 5 6 7 8 9 1010. I dislike rules and regulations that promotes dogma & tradition because I know there are other ways to get the job done 0 1 2 3 4 5 6 7 8 9 1011. I naturally hate to offend people so I may be slow to confront issues because I am waiting for the right time to do it. 0 1 2 3 4 5 6 7 8 9 1012. People see me as a slow starter and they think I don’t like change but I am steady, dependable, controlled 0 1 2 3 4 5 6 7 8 9 1013. I love to work from the background without making noise about my accomplishment 0 1 2 3 4 5 6 7 8 9 1014. I withdraw from aggressive situations, would rather allow peace reign than be confrontational 0 1 2 3 4 5 6 7 8 9 1015. I am ambitious but I take my time and work at my pace 0 1 2 3 4 5 6 7 8 9 1016. I am a perfectionist to the core, I can’t stand disorganized people. 0 1 2 3 4 5 6 7 8 9 1017. I love to work based on rules and regulations and predetermined standards. 0 1 2 3 4 5 6 7 8 9 1018. I need time to think and plan before embarking on any project of journey. I rarely would jump on a trip or any venture without a proper plan and reflection 0 1 2 3 4 5 6 7 8 9 1019. I could be suspicious and critical of people, always weighing the intentions or motives behind whatever they do. 0 1 2 3 4 5 6 7 8 9 1020. I am very detailed and thorough in whatever I do, always trying to do things right leaving no room for error 0 1 2 3 4 5 6 7 8 9 10Section 2 - LOVE LANGUAGE ASSESSMENTHow would you describe yourself?1. I feel more loved, cared for and elated when my partner sends me a loving note for no apparent reason my partner and I hold hands or hug2. I feel more loved, cared for and elated when my partner and I get to spend time together alone with no distractions or interruptions my partner does something practical to help me out.3. I feel more loved, cared for and elated when my partner shows they love me by giving me a gift, no matter how little my partner and i hang out together - just the two of us4. I feel more loved, cared for and elated when my partner pleasantly surprises me by doing something for me they know I am supposed to do my partner and I randomly touch each other or lock eyes together5. I feel more loved, cared for and elated when my partner puts their arm around me when we're at a function or an event my partner surprises me with a gift.6. I feel more loved, cared for and elated when I'm around my partner, even if we're not really doing anything I hold hands with my partner.7. I feel more loved, cared for and elated when my partner buys or gets me a gift. my partner tells me "I love you" 8. I feel more loved, cared for and elated when I sit close to my partner or stand beside them I am complimented by my loved one for no apparent reason9. I feel more loved, cared for and elated when I get the chance to just "hang out" with my partner. I unexpectedly get small gifts from my partner.10. I feel more loved, cared for and elated when I hear my partner tell me, "I'm proud of you." my partner helps me with a task and takes the burden off me11. I feel more loved, cared for and elated when I get to do things with my partner. I hear encouraging words from my partner.12. I feel more loved, cared for and elated when my partner does things for me instead of just talking about doing nice things. I feel connected to my partner through a hug13. I feel more loved, cared for and elated when I hear commendations from my partner. my partner gives me something that shows they were really thinking about me.14. I feel more loved, cared for and elated when I'm able to just be around my partner. I get a back rub or massage from my partner.15. I feel more loved, cared for and elated when my partner reacts positively to something I've accomplished my partner does something for me that I know they don't particularly enjoy.16. I feel more loved, cared for and elated when my partner and I kiss frequently, my partner shows interest in the things I care about.17. I feel more loved, cared for and elated when my partner works on special projects with me that I have to complete. my partner gives me an exciting gift.18. I feel more loved, cared for and elated when I'm complimented by my partner on my appearance my partner takes the time to listen to me and really understand my feelings.19. I feel more loved, cared for and elated when my partner and I share non-sexual touch in public. my partner offers to run errands for me.20. I feel more loved, cared for and elated when my partner does a bit more than their normal share of the responsibilities we share (around the house, work-related, etc). I get a gift that I know my partner put thought into choosing21. I feel more loved, cared for and elated when my partner doesn't check their phone while we're talking my partner goes out of their way to do something that relieves pressure on me.22. I feel more loved, cared for and elated when I can look forward to a holiday because of a gift I anticipate receiving I hear the words, "I appreciate you" from my partner.23. I feel more loved, cared for and elated when my partner brings me a little gift after they've been traveling without me. my partner takes care of something I'm responsible to do but I feel too stressed to do at the time.24. I feel more loved, cared for and elated when my partner doesn't interrupt me while I'm talking. gift giving is an important part of our relationship.25. I feel more loved, cared for and elated when my partner helps me out when they know I'm already tired. I get to go somewhere while spending time with my partner.26. I feel more loved, cared for and elated when my partner and I are physically intimate. my partner gives me a little gift that they picked up in the course of their normal day27. I feel more loved, cared for and elated when my partner says something encouraging to me. I get to spend time in a shared activity or hobby with my partner28. I feel more loved, cared for and elated when my partner surprises me with a small token of their appreciation my partner and I touch a lot during the normal course of the day.29. I feel more loved, cared for and elated when my partner helps me out- especially if I know they're already busy. I hear my partner specifically tell me, "I appreciate you."30. I feel more loved, cared for and elated when my partner and I embrace after we've been apart for a while. I hear my partner say how much I mean to themSection 3 - MARRIAGE ASSESSMENTRead the list of statements and, using the scale below, pick the grade that you feel corresponds to how you feel. Never True Rarely True Occasionally True Usually True Always True1. My partner is my first dial when I experience a great moment of joy or an unexpected moment of sadness Never True Rarely True Occasionally True Usually True Always True2. We are able to apologize and forgive when one of us has hurt the other Never True Rarely True Occasionally True Usually True Always True3. My partner is good at meeting my emotional needs Never True Rarely True Occasionally True Usually True Always True4. My partner considers and respects me in their choices and actions Never True Rarely True Occasionally True Usually True Always True5. We make it a priority to go out together at least once a fortnight Never True Rarely True Occasionally True Usually True Always True6. My partner and I share same beliefs and values Never True Rarely True Occasionally True Usually True Always True7. My partner encourages me in all I do and my spiritual growth Never True Rarely True Occasionally True Usually True Always True8. I am able to talk to my partner about my hopes for the future without fear Never True Rarely True Occasionally True Usually True Always True9. We support each other in the goals we have for our family life Never True Rarely True Occasionally True Usually True Always True10. We share and create beautiful memories together as a couple Never True Rarely True Occasionally True Usually True Always True11. My partner listens to my point of view even when we disagree Never True Rarely True Occasionally True Usually True Always True12. My partner listens to my opinions without interrupting or criticizing me Never True Rarely True Occasionally True Usually True Always True13. My partner constantly gives me their full and undivided attention when I feel like expressing myself. Never True Rarely True Occasionally True Usually True Always True14. We discuss new ideas with each other and make decisions together Never True Rarely True Occasionally True Usually True Always True15. We are able to talk about strong emotions such as excitement, hope, grief and anxiety Never True Rarely True Occasionally True Usually True Always True16. Growing up my parents/guardians respected my uniqueness and encouraged me in my developments Never True Rarely True Occasionally True Usually True Always True17. My parents/guardians have/had a strong loving relationship Never True Rarely True Occasionally True Usually True Always True18. Growing up my parents/guardians spent ample time with me (play with me, talk with me) Never True Rarely True Occasionally True Usually True Always True19. I was raised with increasing freedom and boundaries appropriate for my age Never True Rarely True Occasionally True Usually True Always True20. My parents/guardians remain/remained faithful to each other through thick and thin Never True Rarely True Occasionally True Usually True Always True21. My partner is sensitive towards my sexual needs and makes effort to meet them Never True Rarely True Occasionally True Usually True Always True22. We agree on our sexual practices Never True Rarely True Occasionally True Usually True Always True23. My partner shows me care and comfort through regular non-sexual touching Never True Rarely True Occasionally True Usually True Always True24. I am happy about the frequency of our love-making Never True Rarely True Occasionally True Usually True Always True25. I am able to talk to my partner about my sexual hopes and desires Never True Rarely True Occasionally True Usually True Always True26. We have a marital coach we both respect and always listen to Never True Rarely True Occasionally True Usually True Always True27. Our home has a clear vision & values that is both known to us and everyone in the home Never True Rarely True Occasionally True Usually True Always True28. We have joint goals, interests and vision that we pursue together Never True Rarely True Occasionally True Usually True Always True29. We have a family constitution that guides our conduct which we both respect Never True Rarely True Occasionally True Usually True Always True30. Our marriage has a purpose. Never True Rarely True Occasionally True Usually True Always TrueSection 4 - ATTACHMENT DYNAMICSRead the list of statements and, using the scale below, pick the grade that you feel corresponds to how you feel. Strongly Agree Agree Neutral Disagree Strongly Disagree1. I find it relatively easy to get emotionally close to others. Strongly Agree Agree Neutral Disagree Strongly Disagree2. I often worry about being abandoned or not loved by my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree3. I find it difficult to fully trust others, even my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree4. I feel conflicted about being close to others—I want connection but also fear it. Strongly Agree Agree Neutral Disagree Strongly Disagree5. I feel comfortable depending on others and having others depend on me. Strongly Agree Agree Neutral Disagree Strongly Disagree6. I feel insecure if my partner doesn’t immediately respond to me. Strongly Agree Agree Neutral Disagree Strongly Disagree7. I prefer not to rely on others and feel uncomfortable when they depend on me. Strongly Agree Agree Neutral Disagree Strongly Disagree8. I sometimes push people away even though I deeply want their attention. Strongly Agree Agree Neutral Disagree Strongly Disagree9. I am comfortable sharing my thoughts and feelings with my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree10. I tend to crave a lot of reassurance and affection in my relationships. Strongly Agree Agree Neutral Disagree Strongly Disagree11. I often feel the need to keep emotional distance from others to feel safe. Strongly Agree Agree Neutral Disagree Strongly Disagree12. I experience sudden mood changes in relationships, going from feeling secure to scared or confused. Strongly Agree Agree Neutral Disagree Strongly Disagree13. I feel confident that my partner will support me when I need them. Strongly Agree Agree Neutral Disagree Strongly Disagree14. I sometimes feel that I am more invested in the relationship than my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree15. I am uncomfortable with too much closeness and often push people away. Strongly Agree Agree Neutral Disagree Strongly Disagree16. I have difficulty trusting people and fear they will hurt or abandon me. Strongly Agree Agree Neutral Disagree Strongly Disagree17. I trust my relationships to be stable and secure, even when there’s temporary distance. Strongly Agree Agree Neutral Disagree Strongly Disagree18. I often feel anxious when my partner is not available, even for short periods. Strongly Agree Agree Neutral Disagree Strongly Disagree19. I value my independence and sometimes avoid sharing my feelings with my partner. Strongly Agree Agree Neutral Disagree Strongly Disagree20. I often feel overwhelmed by emotions and struggle to express them clearly in relationships. Strongly Agree Agree Neutral Disagree Strongly Disagree21. I am generally satisfied with the level of closeness in my relationships Strongly Agree Agree Neutral Disagree Strongly Disagree22. I fear that my partner might not care about me as much as I care about them. Strongly Agree Agree Neutral Disagree Strongly Disagree23. I find it challenging to be emotionally vulnerable, even with people I care about. Strongly Agree Agree Neutral Disagree Strongly Disagree24. I tend to experience intense emotional reactions when I feel rejected or ignored. Strongly Agree Agree Neutral Disagree Strongly DisagreeSection 5 - BELIEFS ALIGNMENTRead each statement and indicate whether you Agree, Disagree, or are Unsure. Be honest, as this will help guide meaningful discussions about your future together.1. A husband is superior to his wife. Agree Disagree Unsure2. It is the duty of a woman to cook for the family. Agree Disagree Unsure3. The man should have the final say in every matter that concerns the family. Agree Disagree Unsure4. A husband and wife are teammates. Agree Disagree Unsure5. Our cultural backgrounds should not define gender roles in our marriage. Agree Disagree Unsure6. Christian faith beliefs and principles should guide our decision-making in marriage. Agree Disagree Unsure7. Financial responsibilities in marriage should be divided equally. Agree Disagree Unsure8. Each spouse should have the freedom to manage their own money without consulting the other. Agree Disagree Unsure9. If one partner earns significantly more, they should have more decision-making power over finances. Agree Disagree Unsure10. It is acceptable to have separate bank accounts in addition to a joint account. Agree Disagree Unsure11. Whatever couples earn must be open to everyone in the family & no one owns anything privately. Agree Disagree Unsure12. I believe a real man must be the breadwinner and must provide for his family. Agree Disagree Unsure13. In marriage, one person should have the final say when there is a disagreement. Agree Disagree Unsure14. Household responsibilities should be shared based on ability, not gender roles. Agree Disagree Unsure15. Both partners should have an equal say in parenting decisions. Agree Disagree Unsure16. The final say on a matter (family plans, projects, etc) should be based on gender roles, not on expertise in those areas of concern. Agree Disagree Unsure17. It is important to balance individual independence with unity in marriage. Agree Disagree Unsure18. If a major decision negatively affects one spouse, it should be reconsidered. Agree Disagree Unsure19. Each partner should have personal time and space without feeling guilty. Agree Disagree Unsure20. It is okay to have close friendships with the opposite gender in marriage. Agree Disagree Unsure21. Social media and phone privacy should be respected in marriage. Agree Disagree Unsure22. Accountability should be mutual and not one-sided Agree Disagree Unsure23. Marriage does not mean giving up personal hobbies and interests. Agree Disagree Unsure24. Family members and friends should pre-inform before they visit. Agree Disagree Unsure25. Career choices should be made with the family’s best interest in mind. Agree Disagree Unsure26. If one partner gets a great job opportunity in another location, the other should be willing to relocate. Agree Disagree Unsure27. There will be disrespect and marital issues if a wife earns more than her husband. Agree Disagree Unsure28. If work demands more time, family should understand and adjust accordingly. Agree Disagree Unsure29. Marriage should not prevent either partner from furthering their education. Agree Disagree Unsure30. Both partners should actively support each other’s career growth and dreams. Agree Disagree UnsureSubmit Form
