page 1 of 2

Relationship evaluation form

The purpose of this evaluation form is to learn of your opinions on, and experiences of, our previous relationship; both to improve the
quality of my future relationships and also so that we can compare our thoughts on the one we had. Answer the questions by
crossing the checkbox that most closely corresponds to your opinion; the questions without checkboxes are open-ended and you can
write whatever answer you like to those questions (if your answer does not fit, use the back of the page). If there is a question you
do not wish to answer you can leave it blank.

Name: ____________________________________ Age: _____ Sex: _____ Birthday:__________________

Location: ____________________________ Contact No.: _______________ Date: ____________________

Position: _____________________________________ Evaluatee's Name: ___________________________

1) What attracted you to me before we were together? 9a) Have you consciously tried to change yes no
me during our relationship?

9b) If yes, what did you try to change?

Education
Religion
Political views
2) What do you think attracted me to you? Humour
Eating habits
Taste in music
Taste in clothes
Sexual habits
Other:_________
3a) Did you try to alter yourself to gain my yes no no some totally
9c) Did you succeed?
appreciation before our relationship?

3b) If yes, what did you try to alter? 10) How did our differences in the following categories
affect our relationship?
negatively not at all positively
Education
Religion
Ethnicity
4) Who initiated the relationship, you I both Class
according to you?
Political views
Intelligens
5a) How long did the relationship last according to you? Creativity
Age
Humour
5b) How long did you think the relationship would last? Eating habits
Taste in music
Taste in clothes
5c) How long did your friends think the relationship would last? Sexual habits

11a) Were you ever in love with me? yes no

11b) Do you think that I was ever in love yes no

6) How have your friends affected your relationship with me?
with you?
negatively not at all positively
11c) Did you ever think that I was "the one"? yes no

7a) Who initiated the break-up? you I both 11d) Do you think that I ever thought you yes no
were "the one"?

7b) If you did, did you give me the yes no

real reason why? 12a) Were you looking for other possible yes no
relationships during our relationship?
7c) If I did, do you think I gave you yes no yes no
12b) Do you think that I was?
the real reason why?

7d) Did our relationship end the way yes no

you thought if would? 13a) Did you tell me any big lies during yes no
our relationship?

8) Do you miss me? no sometimes yes 13b) Do you think that I did? yes no
 page 2 of 2

14) Was our sexual life predictable? yes no 22a) What turned you on the most about me?

15) How am I as a lover compared to

your previous experiences? 22b) What turned you off the most about me?

poor okey wonderful

22c) What do you think turned me on about you?

16a) Do you regret something sexual that yes no
we did?

16b) If yes, what?

23a) Did you fantasize about no occasionally always

others when we had sex?
17a) Do you regret anything sexual that yes no
we didn't do? 23b) Do you think that I did? no occasionally always

17a) If yes, what?

24a) Did you consider having sex with yes no

others during our relationship?

24b) Did you have sex with others during yes no

18) Was one of us the sexually you I none
more dominant? our relationship?

24c) If yes, on how many 1 2 3 4 5<

19a) Were you ever afraid of me sexually? occasions?
no occasionly always
And with how many
persons totally? 1 2 3 4 5<
19b) Did I ever force you into having sex?
no occasionly always 24d) How was that sex worse same better
compared to our sex?

19c) Do you think that you ever forced 24e) How did the sex
me into having sex? negatively not at all positively
no occasionly always affect our relationship?

20) Hos was our sexual life according to the following criteria? 25) Do you think that I had sex with yes no
other people during our relationship?
poor okey wonderful
Spontaneity
Openness 26) How do you judge my intimite hygiene?
Experimentation poor okey perfect
Tenderness
Dominance

27) How do you judge the taste of my semen/vaginal juices?

21) Did you ever fake orgasm during sex? yes no
repulsive okey tasty

28) How do you judge my different bodyparts? 29) During sex, how much attention did I
pay to the different parts of your body?
ugly okay beautiful too little enough too much
Eyes Head
Nose Neck
Mouth Torso
Torso Nipples
Arms Arms
Hands Hands
Butt Butt
Genitals Genitals
Legs Legs
Feet Feet

IN WITNESS WHEREOF, the undersigned, acknowledges that this form was discussed and reviewed.

Evaluatee signature :___________________________________________ Date: ______________

Evaluation performed by :_______________________________________ Date: ______________