| RPT |
.| .| Couple Satisfaction Index| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
conjunction with other diagnostic activities and procedures.| $~
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | CSI Score: <-CSI->| | | Questions and Answers| | 1. Please indicate the degree of happiness, all things considered,
of your relationship.| <*Answer_6484*>| 2. In general, how often do you think that things between you and your partner are going well?| <*Answer_6485*>| 3. Our relationship is strong.|
<*Answer_6486*>| 4. My relationship with my partner makes me happy.| <*Answer_6487*>| 5. I have a warm and comfortable relationship with my partner.| <*Answer_6488*>| 6. I really feel like
part of a team with my partner.| <*Answer_6491*>| 7. How rewarding is your relationship with your partner?| <*Answer_6492*>| 8. How well does your partner meet your needs?|
<*Answer_6494*>| 9. To what extent has your relationship met your original expectations?| <*Answer_6497*>| 10. In general, how satisfied are you with your relationship?| <*Answer_6559*>| 11.
My relationship is boring vs. interesting:| <*Answer_6732*>| 12. My relationship is bad vs. good:| <*Answer_6733*>| 13. My relationship is empty vs. full:| <*Answer_6734*>| 14. My
relationship is fragile vs. sturdy:| <*Answer_6735*>| 15. My relationship is discouraging vs. hopeful:| <*Answer_6736*>| 16. My relationship is miserable vs. enjoyable:| <*Answer_7294*>|
| | Information contained in this note is based on a self-report assessment and is not sufficient to use alone for diagnostic purposes. Assessment results should be verified for accuracy and used in
|
