| Name: | |
| Address: | |
| City: | |
| State: | |
| Zip: | |
| Telephone: | |
| Email address: | |
| Age: | |
| Astrological sign (if known): | |
| Height: | |
| Weight: | |
| Eye color: | |
| Hair Color: | |
| Occupation: | |
| Education: | |
| Religion: | |
| Relationship Status: | |
| Do you have children? If so, please tell us about him/her |
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| Do you Smoke? | Yes No
If so, how often? |
| Do you drink alcoholic beverages? | Yes No
If so, how often? |
| Do you exercise? | |
| Do you go for regular medical check-ups? | |
| Are you sexually active? | |
| Is sex an important part of your relationship? | |
| Are you financially secure? | |
| Please list some of your hobbies: |
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| How would you describe your sense of humor? |
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| Which is your favorite season (spring, summer, fall, winter), and why? |
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| Do you like to dance? If yes, what type of dance do you enjoy? |
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| What type(s) of music do you enjoy? |
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| What do you like to do for fun? |
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| What is the last book you read? | |
| What kinds of sports and exercises do you enjoy? (please circle all that apply) |
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| Which of the following describes your daily diet? (please circle) |
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| Do you have any pets? If so, please list: |
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| How would you describe an ideal date? |
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| Which would you prefer to do on a date? (Please choose one) |
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| Who has been your most influential person in your life, other than your parents and why? |
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| What are 3 things you are most thankful for? |
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| Please choose from the list below all that best describe you: |
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| Choose 4 descriptions below that your friends would say describe you. |
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| How would each of the following describe you: |
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| Please select whether the statements pertains to you (True) or not (False) |
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