Romance Questionnaire

This Romance Questionnaire is not intended to be a diagnostic tool but instead is meant to give you and I a better idea of the level of romance in your relationship.

Answer the questions below to the best of your ability.

Rate your answers as follows:

(1) Sometimes
(2) Often
(3) Never - or I don't know

1. My partner and I go out to romantic places just to be alone together at least once a week.

1	2	3

2. If I am under more stress than usual, my partner will usually do extra things for me.

1	2	3

3. My partner frequently surprises me by doing something romantic.

1	2	3

4. I am afraid that if I do something romantic, my partner will think it is silly.

1	2	3

5. Sex should always follow romantic situations.

1	2	3

6. My partner and I celebrate special days together almost once a month.

1	2	3

7. I frequently fantasize about my partner.

1	2	3

8. When I refer to myself, I frequently say "we" (meaning my partner and I).

1	2	3

9. I am extremely attracted to my partner sexually.

1	2	3

10. If I ask my partner to do a favor for me, he/she usually does it cheerfully.

1	2	3

11. I do something different to surprise my partner such as buy flowers, leave a love note, or buy a present for no special event or reason at least once a week.

1	2	3

12. Most people think that my partner is physically attractive.

1	2	3

13. Overall, I am happy with the amount of romance in my relationship.

1	2	3

14. I enjoy spending time thinking about romantic things I can to for my partner.

1	2	3

15. My partner and I both playfully tease each other several times per week.

1	2	3

16. My partner is charming and romantic.

1	2	3

17. My partner and I both agree that romance is a priority in our relationship.

1	2	3

Congratulations on completing this questionnaire. Enter your contact information below and I will contact you within the next day to discuss your results and find out if you would like to schedule an appointment.

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Dr. Randi Fredricks Ph.D. is a Psychotherapist and licensed as a Marriage Family Therapist MFC 47803. Dr. Fredricks is not licensed with the California Medical
Board or the California Bureau of Naturopathic Medicine. © 2012 Randi Fredricks, Marriage and Family Therapist, Inc. All rights reserved. Serving
San Jose, Sunnyvale, Santa Cruz, Palo Alto, Monte Sereno, Los Gatos, Cupertino, Mountain View, Scotts Valley, Campbell, Willow Glen, and Milpitas CA.