149 (149)    MH REPORT (601.93)

.| .| Couple Satisfaction Index Partner Version| | 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 Partner Score: <-CSI-PV->| | | 1. Partner's Name: <*Answer_7337*>| | | Questions and Answers| | 2. Please indicate the degree of happiness, all things considered, 
of your relationship.|     <*Answer_7336*>| 3. In general, how often do you think that things between you and your partner are going well?|     <*Answer_6485*>| 4. Our relationship is strong.|     
<*Answer_6486*>| 5. My relationship with my partner makes me happy.|     <*Answer_6487*>| 6. I have a warm and comfortable relationship with my partner.|     <*Answer_6488*>| 7. I really feel like 
part of a team with my partner.|     <*Answer_6491*>| 8. How rewarding is your relationship with your partner?|     <*Answer_6492*>| 9. How well does your partner meet your needs?|     
<*Answer_6494*>| 10. To what extent has your relationship met your original expectations?|     <*Answer_6497*>| 11. In general, how satisfied are you with your relationship?|     <*Answer_6559*>| 12. 
My relationship is boring vs. interesting:|     <*Answer_6732*>| 13. My relationship is bad vs. good:|     <*Answer_6733*>| 14. My relationship is empty vs. full:|     <*Answer_6734*>| 15. My 
relationship is fragile vs. sturdy:|     <*Answer_6735*>| 16. My relationship is discouraging vs. hopeful:|     <*Answer_6736*>| 17. 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