A SAMPLE OF SURVEY QUESTIONS
Name _________________________
Good friends call me _______________
CIRCLE ALL THAT APPLY
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:
Single Open relationship Attached, but looking
Committed / Monagamous Prefer not to say
Do you have children?
Have children living at home Have children, but not
living at home Do t have children
Your HIV status:
Negative Positive Not Sure
Your age range:
Under 30
30-40
40-50
59-60
60 or better
You consider looks to be:
The most important thing Very Important
Moderately Important Not Important
You consider intelligence to be:
The most important thing Very Important
Moderately Important Not Important
Your favorite time of day:
Morning person Night person Up all the time
You prefer to live in:
Big City Suburbia Small town Middle of Nowhere
Your political orientation:
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:
Adventurous
Argumentative
Artistic
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:
Activist
Bear
Blue Collar
Circuit Party
Country/Western
Drag
Gym Bunny
Hippie/Grala
Homebody
Jock/Sporty
Leather
Military/Cop
Preppy
Professional
Your favorite cuisines:
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:
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:
Fiction
Magazines
Newspapers
Non-Fiction
Poetry
Trade Journals
Your favorite movie genres:
Action/Adventure
Comedy
Drama
Foreign/Independent
Horror
Romance
Sci-Fi
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