Healthy Relationship Checklist
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
Please Select
Male
Female
N/A
Your Age
How long have you been together?
Rows
Yes
No
Notes
I feel loved.
1
2
I feel respected.
3
4
I feel acknowledged.
5
6
We discuss things regularly.
7
8
We disagree sometimes but usually reach a compromise.
9
10
We talk openly and honestly about most issues.
11
12
We negotiate on issues that are more important to one party.
13
14
My partner listens to me.
15
16
I am good at admitting it to my partner when I am wrong or have made a mistake.
17
18
My partner accepts responsibility when he/she has made a mistake and apologizes.
19
20
I can be myself when I am with my partner.
21
22
My partner has a good sense of humor.
23
24
It’s okay if we don’t agree sometimes.
25
26
My partner asks me how I feel.
27
28
My partner respects me.
29
30
My partner likes me the way I am and doesn’t try to change me.
31
32
My partner asks me what I think.
33
34
My partner wants me to succeed.
35
36
My partner is honest with me.
37
38
My partner admits to mistakes.
39
40
My partner sticks to our agreements.
41
42
Conflict drives us apart.
43
44
When I am tired I sometimes say hurtful things to my partner.
45
46
Our arguments are destructive to one or both parties.
47
48
My partner puts me down.
49
50
My partner insults me.
51
52
My partner blames me for everything that goes wrong.
53
54
My partner lies to me.
55
56
I feel on edge when I’m out with my partner, I can’t relax or unwind.
57
58
My partner cheats on me.
59
60
My partner lies about hurting me.
61
62
My partner makes important decisions without me.
63
64
My partner makes me do all the work.
65
66
My partner yells at me.
67
68
My partner sometimes hurts me physically.
69
70
My partner won’t let me see my friends.
71
72
My partner lies to me about money.
73
74
My partner takes all the money.
75
76
I can’t be myself when I am with my partner.
77
78
I don’t feel like my partner listens to me.
79
80
We often fight and lose our tempers.
81
82
My partner does not prioritize our relationship when they should.
83
84
My partner shares the work that supports us.
85
86
My partner trusts and supports me.
87
88
My partner loves me for who I am.
89
90
We communicate well.
91
92
We share equal responsibility for our relationship
93
94
We make time for each other.
95
96
We have similar friends and separate friends.
97
98
When we host friends, my partner helps do things that need to get done.
99
100
My partner thinks it’s okay when I spend time with my friends.
101
102
I feel strong in myself and not overshadowed by my partner.
103
104
My partner understands and accepts my family.
105
106
I am not insecure when my partner wants time alone.
107
108
We understand each other’s family dynamics.
109
110
My partner does nice things for me.
111
112
My partner believes in me.
113
114
My partner makes me feel safe.
115
116
We share responsibility for the practical things in life.
117
118
We remember important dates and events.
119
120
We take care of ourselves as well as each other.
121
122
We try to understand each other’s needs, desires
and expectations.
123
124
We genuinely like each other and love spending
time together.
125
126
We freely and openly express our love.
127
128
We are compassionate toward each other.
129
130
We share financial responsibility.
131
132
My partner doesn’t waste our money.
133
134
My partner is a good parent.
135
136
My partner helps the kids feel good about themselves.
137
138
We share parenting values.
139
140
We share parenting responsibilities.
141
142
My partner doesn’t think he/she is ever in the wrong.
143
144
My partner is inconsiderate of my needs.
145
146
My partner expects me to fall in with his/ her plans.
147
148
My partner never asks me about my day or my life.
149
150
My partner is not supportive of my parenting techniques.
151
152
My partner is uninvolved in our home and family life.
153
154
Given a choice, my partner wouldn’t choose to spend his / her free time with me and our children.
155
156
My partner is influenced heavily by what his / her friends think.
157
158
We do not have an intimate relationship as often
as we used to.
159
160
My partner doesn’t seem to find me attractive anymore.
161
162
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Should be Empty: