MARITAL PROBLEMS QUESTIONNAIRE
Please answer all questions, regardless of gender. Thank you.
Age: ____ Sex:_____ Last Year of Education _____ Occupation ______
Religious affiliation:______
Years married to current spouse ______Number of children together ______
Number of these children still living in your home _____
Have you been married before? ______Has your spouse been married before? ______
How many serious arguments have you had in the past year? ______
Have your problems ever been serious enough to make you discuss separation or divorce? ____
Have you been separated (because of problems) in the past year? ______
Overall, how happy are you in your current marriage? ______
Rate each area in terms of how much a problem it is in your marriage by using the following scale:
0 = This area almost never (less than once a year) causes conflict
1 = This area rarely (1-4 times/year) causes conflict
2 = This problem causes occasional (5-10 times/year) conflict
3 = This problem causes frequent (monthly) conflict
4 = This problem causes weekly conflict
(mark n/a if not applicable)
1. Husband's friends ____ 2. Wife's friends ____
3. Husband's family ____ 4. Wife's family ____
5. Husband's friends of opposite sex___ 6. Wife's friends of opposite sex ____
7. Husband's job ____ 8. Wife's job _____
9. Husband's mood/temper ____ 10. Wife's mood/temper ____
11. Husband's honesty _____ 12. Wife's honesty ____
13. Husband's behavior at social events ____ 14. Wife's behavior at social events____
15. Husband's support in crisis ____ 16. Wife's support in crisis ____
17. Religious beliefs ____ 18. Church attendance ____
19. Charitable gifts ____ 20. Love and affection ____
21. Sexual activities ____ 22. Sexual frequency ____
23. Sexual infidelity ____ 24. Saving/investment ____
25. Paying bills ____ 26. Spending money on clothes or hobbies ____
27. Use of credit cards ____ 28. Long range goals and priorities____
29. Family activities ____ 30. Use of vacation and leisure time ____
31. Resolving differences of opinion ____ 32. Communication ____
33. Companionship ____ 34. Agreement upon who is "head" of household ___
35. Household chores ____ 36. Discipline of children ____
37. Intellectual discussion ____ 38. Gambling ____
39. Alcohol/drug use ____ 40. Pornography ____
41. List any other problem
42. Which problem is most serious to you? ____