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First Date and/or Break-up Exit Interview

1. Describe the main reason we won't be romantically linked going forward:
If other, please explain:
2. How would you describe my abilities as a love interest:
If other, please explain:
3. Does your not seeing me anymore have anything to do with (choose one):
Fill in the blank for E or Other, please explain:
4. What was your favorite quality of mine?
Did you really think I would put an 'other' for this one?Empty
5. What was one thing I need to work on?
If other, please explain:
6. Describe any extenuating circumstances that have nothing to do with me and will make me feel better about your decision (choose all that apply):Empty
a) I have a boyfriend/girlfriend.
b) I have a husband/wife.
c) I have a fear of committing to anyone or anything. Seriously, I won't even sign a contract for my cell phone service.
d) I'm gay and/or strait (but just realized it).
e) I'm moving.
f) Other
If other, please explain:
Additional Comments and/or Beseeching for Reconcilement:

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