Intimacy Survey for Married Couples

Click here to download and print the survey. After you and your spouse have completed the survey, set aside a special date night to go over your responses together. Pray together to thank God for what�s working well and ask God for the grace to take steps to deepen your intimacy.

Alternatively, you could fill in the survey using our online form below. We appreciate you taking the time to share your responses with us in our ongoing mission to help couples come to deeper levels of intimacy.

Intimacy Survey for Married Couples

Please note that all fields followed by an asterisk must be filled in.

First Name

E-mail Address

Your Gender*
Your Gender*

	Male
	Female

How long have you been married?*
How long have you been married?*

	Less than 5 years
	Between 5 and 10 years
	Between 10 and 15 years
	Between 15 and 20 years
	Between 20 and 30 years
	Between 30 and 40 years
	More than 40 years

Spiritual Intimacy (check all that apply)

	I pray regularly throughout the day for my spouse.
	We pray together regularly.
	We read/study the Bible together.
	I am comfortable sharing with my spouse what God is teaching me.
	For Wives only: My husband actively leads me spiritually.
	For Husbands only: I take my role as spiritual leader of my wife/family seriously.
	During times of conflict, we pray together inviting God to help each of us change.

Intellectual Intimacy (check all that apply)

	I pay attention to my spouse�s interests and hobbies.
	I feel that my spouse supports me in my personal interests.
	My spouse and I try to learn more about what we believe and think on lot of topics.
	My spouse's choice of interests and hobbies make me feel proud of him/her.
	I feel free to express my opinion even though my spouse may disagree with me.
	We agree on what our core values and beliefs are.
	I can fully trust my spouse and allow myself to be vulnerable with him/her.

Emotional Intimacy (check all that apply)

	I feel cherished and cared for by my spouse.
	My spouse and I enjoy romancing one another.
	We say �I love you� to one another often.
	My spouse and I spend quality time together almost every day.
	I enjoy spending time in conversation with my spouse.
	My spouse is my very best friend!
	We have learned how to handle conflict with one another.
	My spouse rarely interrupts me when I�m talking.
	We still hold hands in public.
	My spouse surprises me with loveletters, small gifts, and other expressions of romance.
	For Wives: my husband usually remembers special dates (my birthday, our anniversary)
	For Husbands: I rarely forget to celebrate special dates.
	My spouse expresses his/her appreciation of me and what I do.
	We are so busy that we only have time to �connect� at the end of the day.
	My spouse is still holding a grudge even though I�ve asked for forgiveness.
	I find I get distracted easily when my spouse is talking with me.
	We almost never go out for a �date night� or a �weekend getaway� just with the two of us.
	My spouse spends more time in front of the TV than communicating with me.

Sexual Intimacy (check all that apply)

	My spouse and I are comfortable talking about sex.
	We laugh and have fun during sex.
	My spouse and I know where to find the female g-spot.
	Our sex life has improved in the past year.
	My spouse and I kiss more now than in our first year of marriage.
	I initiate sex at least 25% of the time.
	We try to include variety in our sexual relationship.
	I feel my sexual needs are being met.
	I�ve told my spouse what feels good and what I enjoy in our sexual relationship.
	My spouse is not as interested in sex as I am.
	I struggle with pornography.
	Sometimes I find sex boring.
	There are new things I�d like us to try when having sex, but I�m too embarrassed to ask my spouse.
	For Wives only: I rarely experience orgasm.
	For Husbands only: My wife has difficulty reaching orgasm.
	We are so busy that sex is usually rushed.
	I am often too tired for sex.
	Sometimes I don�t feel sexually confident with my spouse.

On average, how often do you and your spouse have sex?

	�Always�: at least once a day
	Often: several times per week
	Regularly: once per week
	Occasionally: 2 or 3 times per month
	Seldom: less than once per month
	Rarely: �we go without sex for months at a time�

Select the word that best describes your sexual relationship with your spouse.

	Non-Existent 0/10
	Disappointing 1/10
	Boring 2/10
	Take it or Leave it 3/10
	Sub-Standard 4/10
	Adequate 5/10
	Improving 6/10
	Pleasurable 7/10
	In a Good Place 8/10
	Almost Perfect 9/10
	In Heaven! 10/10

Please enter the word that you see below.

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