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The Survey 

 

 


Name  _________________________

 

Good friends call me  _______________

 

We can schedule dinner parties on any night restaurants

are open.  Which night of the week is ordinarily

best for you?     M      T      W      TH      F      SAT      SUN

 

What dinner time is best for you:   6 PM   7 PM    8 PM

 

Your relationship status:  <Circle One>

  Single    Open relationship    Attached, but looking      

  Committed / Monagamous         Prefer not to say  

 

Do you have children?  <Circle One>

  Have children living at home    Have children, but not    

  living at home      Do not have children 

 

Your HIV status:

  <Circle One> Negative      Positive       Not Sure 

 

Your age range:

Under 30

 

30-40

 

40-50

 

59-60

 

60 or better

 

 

You consider looks to be: <Circle One>    

    The most important thing      Very Important 

    Moderately Important             Not Important    

 

You consider intelligence to be:  <Circle One>    

The most important thing      Very Important        

Moderately Important             Not Important    

 

Your favorite time of day:  <Circle One>

  Morning person       Night person   Up all the time  

 

You prefer to live in: <Circle One>

  Big City   Suburbia   Small town   Middle of nowhere 

 

Your political orientation:  <Circle One>

Extreme liberal        Liberal          Moderate             

Conservative          Extreme conservative 

 

In my life spirituality or religion is:

  Unimportant       Important      Very Important

 

I consider myself:

  Catholic          Protestant         Jewish       Other

 

 

 

 

 

Your pet(s):

Don't have pets

 

 

Bird

 

 

 Cat

 

 

 Dog

 

 

 Fish

 

 

 Reptile

 

 

 Other

 

 

 

Others would describe you as:    Yes                           No 

 Adventurous

 

 

 Argumentative

 

 

 Artistic

 

 

 Bitchy

 

 

 Clean-cut

 

 

 Compulsive

 

 

 Easygoing

 

 

 Eccentric

 

 

 Flamboyant

 

 

 Flexible

 

 

 Flirtatious

 

 

 Funny

 

 

 High Energy

 

 

 High Maintenance

 

 

 Intellectual

 

 

 Loving

 

 

 Low Maintenance

 

 

 Musical

 

 

 Nurturing

 

 

 Outgoing

 

 

 Practical

 

 

 Procrastinator

 

 

 Quiet

 

 

 Romantic

 

 

 Sensitive

 

 

 Serious

 

 

 Shy

 

 

 Simple

 

 

 Sophisticated

 

 

 Spontaneous

 

 

 Stubborn

 

 

 Talkative

 

 

 Wild

 

 

 Witty

 

 

  

 

 

 

 

 

 

 

 

Your scene:                            Yes                       No 

 Activist

 

 

 Bear

 

 

 Blue Collar

 

 

 Circuit Party

 

 

 Country/Western

 

 

 Drag

 

 

 Gym Bunny

 

 

 Hippie/Granola

 

 

 Homebody

 

 

 Jock/Sporty

 

 

 Leather

 

 

 Military/Cop

 

 

 Preppy

 

 

 Professional

 

 

 

 

Your favorite cuisines:           Yes                       No 

 American

 

 

 Barbecue

 

 

 Cajun

 

 

 Caribbean/Cuban

 

 

 Chinese

 

 

 Continental

 

 

 French

 

 

 German

 

 

 Greek

 

 

 Indian

 

 

 Italian

 

 

 Japanese/Sushi

 

 

 Jewish/Kosher

 

 

 Korean

 

 

 Mexican

 

 

 Middle Eastern

 

 

  Seafood

 

 

 Soul food

 

 

 South American

 

 

 Southwestern

 

 

 Spanish

 

 

 Thai

 

 

 Vegetarian/Organic

 

 

 Vietnamese

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

Your favorite music:                    Yes                No  

 Alternative

 

 

 Big Band/Swing

 

 

 Blues/Folk

 

 

 Christian

 

 

 Classic Rock n' Roll

 

 

 Classical

 

 

 Country

 

 

 Dance/Electronica

 

 

 Disco

 

 

 Easy listening

 

 

 Heavy Metal

 

 

 Jazz

 

 

 Latin

 

 

 Modern Rock 'n Roll

 

 

 New Age

 

 

 Oldies

 

 

 Opera

 

 

 Pop/Top 40

 

 

 Rap/Hip hop

 

 

 Reggae

 

 

 Show tunes

 

 

 Soul/R&B

 

 

 World music

 

 

 

You like to read:        Yes                  No                 

 Fiction

 

 

 Magazines

 

 

 Newspapers

 

 

 Non-Fiction

 

 

  Poetry

 

 

 Trade Journals

 

 

 

 

Your favorite movie genres:      Yes             No      

 Action/Adventure

 

 

 Comedy

 

 

 Drama

 

 

 Foreign/Independent

 

 

 Horror

 

 

 Romance

 

 

 Sci-Fi