E-book Work Book Sample
On a scale of 1-9, with one being the 'least' and nine as the 'most' rate each segment to the best of your ability.
I have no need for affection
1 2 3 4 5 6 7 8 9
I have a moderate need for affection
1 2 3 4 5 6 7 8 9
I have a great need for affection
1 2 3 4 5 6 7 8 9
How often would you like your spouse to be affectionate to you?
_______________ times each: day, week, month (circle one).
If you are not shown affection by your spouse as often as you indicated above, how does
it make you feel (circle the appropriate letter)?
a. Very unhappy. c. Neither happy nor unhappy.
b. Somewhat unhappy. d. Happy not to be shown affection.
B. Evaluation of spouse’s affection:
Indicate your satisfaction with your spouse’s affection toward you by circling the appropriate number.
1 2 3 4 5 6 7 8 9
I am extremely dissatisfied
1 2 3 4 5 6 7 8 9
I am neither satisfied nor dissatisfied
1 2 3 4 5 6 7 8 9
I am extremely satisfied
1 2 3 4 5 6 7 8 9
I have no need for affection
1 2 3 4 5 6 7 8 9
I have a moderate need for affection
1 2 3 4 5 6 7 8 9
I have a great need for affection
1 2 3 4 5 6 7 8 9
How often would you like your spouse to be affectionate to you?
_______________ times each: day, week, month (circle one).
If you are not shown affection by your spouse as often as you indicated above, how does
it make you feel (circle the appropriate letter)?
a. Very unhappy. c. Neither happy nor unhappy.
b. Somewhat unhappy. d. Happy not to be shown affection.
B. Evaluation of spouse’s affection:
Indicate your satisfaction with your spouse’s affection toward you by circling the appropriate number.
1 2 3 4 5 6 7 8 9
I am extremely dissatisfied
1 2 3 4 5 6 7 8 9
I am neither satisfied nor dissatisfied
1 2 3 4 5 6 7 8 9
I am extremely satisfied
1 2 3 4 5 6 7 8 9