| RPT |
.| .| Couple Satisfaction Index-4| | Date Given: <.Date_Given.>| Clinician: <.Staff_Ordered_By.>| Location: <.Location.>| | Veteran: <.Patient_Name_Last_First.>| SSN: <.Patient_SSN.>| DOB:
<.Patient_Date_Of_Birth.> (<.Patient_Age.>)| Gender: <.Patient_Gender.>| | | | CSI-4 Score: <-CSI-4->| | | Questions and Answers| | 1. Please indicate the degree of happiness, all things considered,
of your relationship.| <*Answer_6484*>| 2. I have a warm and comfortable relationship with my partner.| <*Answer_6488*>| 3. How rewarding is your relationship with your partner?|
<*Answer_6492*>| 4. In general, how satisfied are you with your relationship?| <*Answer_6559*>|
| | 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 conjunction with other diagnostic activities and procedures.| $~
|
