Survey about your past relationship



Please answer the following questions honestly.

1. How old are you?

years

2. What is your gender?



3. What is your country of origin?



4. What is your ex-partner's name?



5. How long were you in romantic relationship (dating or married) with your ex-partner before you broke up?

years   months

6. How long has it been since you and your ex-partner broke-up?

years   months

7. Please indicate which of the following statements describes your break-up with your ex-partner. Please feel free to check as many as you wish.

My ex-partner initiated the break-up.
I initiated the break-up.
The break-up was mutual.
My ex-partner and I broke up and got back together several times before this break-up.

8. Describe a time when you thought your ex-partner might not be the right person for you.


If there was never a time when you thought your ex-partner might not be the right person for you, please check here.



Please indicate how much you agree with the following statements.

9. I miss my ex-partner.
Strongly Disagree Strongly Agree

10. The thought of being intimate with my ex-partner disgusts me.
Strongly Disagree Strongly Agree

11. I do not want to see or talk to my ex-partner.
Strongly Disagree Strongly Agree

12. If my ex-partner wanted to, I would get back together with him or her.
Strongly Disagree Strongly Agree

13. I try not to think about my ex-partner.
Strongly Disagree Strongly Agree

14. Sometimes I cannot remember why I ever liked my ex-partner.
Strongly Disagree Strongly Agree