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Romantic/Relationship Questionnaire
(1) Do you spend a large amount of time obsessing/fantazing about romantic
interludes and/or relationships? If so, approximately how many hours in a day?
How many days a week?
(2) Have you felt hopelessness, depression and/or suicidal thoughts
associated with romantic situations and/or relationships?
(3) Do you use alcohol, drugs, food or other compulsive behaviors in
association with romatic interludes and/or issues in relationships?
(4) Do you feel guilt, shame or despair after a romantic situation and/or after
spending time with someone in a relationship?
(5) When you meet men/women do you mentally screen them as
romatic/relationship potentials?
(6) Have you spent any period of time out of romantic and/or relationships in
the last five years? Explain the pattern.
(7) Have you experienced an escalating pattern of increased frequency,
duration or type of romantic situations and/or relationships? Please explain.
(8) Have you experienced severe mood shifts before, during or after these
situations?
(9) Did your parents experience troubled relationships? (e.g., multiple affairs,
sexual difficulties, one relationship after another?)
(10) Does you partner(s) ever complain about your romantic fantasies and/or
relationship?
(11) Have you been unable to stop your romantic/relationship behaviors even
though you have promised yourself you would?
(12) Has your romance/relationship behavior created problems for you and/or
your family? What are they?
(13) Has your romance/relationship behavior created problems for you at
work? (e.g., involvement, time lost, decreased concentration)
(14) Has your romance/relationship behavior created problems with your
health? (e.g., sleep, eating, exhaustion, other physical disorders)
(15) Have you sought help for romance/relationship problems before?
(16) Do you have any feeling or fear being alone for periods of time?
(17) Have you felt you must hide or not talk about your relationships and/or
deal with stress?
(18) Have romance and/or relationships been a way to escape from problems
and/or deal with stress?
(19) Have you found yourself not making plans with friends so as to leave your
schedule open for possible romantic/relationship encounter?
(20) Do you attempt to leave destructive or unsatisfying relationships and find
you can't?
(21) Do you masterbate on a regular basis? What is your pattern? Are objects
involved?
(22) Do you spend an inordinate amount of time watching soap operas,
reading romance novels and/or searching for romantic movies?
If you answered 'yes' to 5 or more of these questions, you may have a
dependency and/or addiction problem.
Sue Neufeld-Ellis
Copyright 1992
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