Instructions for filling out the questionnaire:

Please fill out the following questionnaire as honestly as you can. If you do not want to answer a question, please just skip it and move on to the next question.

You can answer with as little or as much information as you feel comfortable with. Just remember that the more information you give, the better the reader will understand how and why you answered the main question of this questionnaire…" What would you do if you knew that today was your last day on Earth?".

Please copy and paste your answers (including the question) into the body of your email. Also include your full mailing address and phone number (this is only for my contact with you).

Feel free to use a pseudonym if you'd rather not list your real name.

Please don't hesitate to contact me if you have any questions.

1) What is your first name, age, and gender?

2) Where were you born? (state and country)?

3) What is your career?

4) What is your race/ethnicity?

5) What is your personal religion?

6) Tell me about your family… include parents and siblings personality traits, as well as your own.

7) List the birth order of you and your siblings.

8) What is your role in the family?

9) List any major changes that happened in your family and how they affected you.

10) What was the atmosphere like in your family/home and why?

11) Was your family close, and why or why not?

12) How do you think those around you perceive you?

13) How do you perceive yourself?

14) Are you an optimist or a pessimist, and why?

15) What was your dream as a child?

16) What is your dream today?

17) What is your personal philosophy?

18) Describe your life today.

19) What does success mean to you?

20) What are you most successful at?

21) Who is your hero and why?

22) Has anyone close to you died, and how did it affect you personally?

23) What would you do if you knew that today was your last day on Earth?

24) List your favorite quote here (it can be your own if you have one). Please include the name of who wrote it.

Thank you for submitting your personal questionnaire. I'll be in touch soon!