Questionnaire
 


Have you had unusual personal experiences? Please fill out the following questionnaire. The answers to all questions are confidential and your identity will not be revealed. Be as complete as you can.

E-mail: (required)

 

Date: (optional)

Name: (optional)

Age: (required)

 

Gender: (required)

Male Female

Occupation: (optional)

Address: (optional)

City: (optional)

State/Province: (required)

 

Zip: (optional)

Country: (required)

 

Phone: (optional)

Spouse/Partner's Name: (optional)

Spouse/Partner's Occupation: (optional)

Children's Names and Ages: (optional)

If the answers to any of the following questions are "Yes," please elaborate in the space provided.

Have you ever seen a UFO? If yes, please give a short description of the events surrounding the sighting(s)?

Yes no If yes, please describe:

As a child or an adult, did you ever experience any odd periods of time of an hour or more when you were lost but you don't remember being lost?

yes no If yes, please describe:

Do you have any scars or marks on your body that neither you nor your parents can remember how you received?

yes no If yes, please describe:

While awake have you actually seen a frightening figure ("monster," a "bogeyman," a "witch," or a "Devil") as a child and/or as an adult in your bedroom, closet, or anywhere else?

yes no If yes, please describe:

Have you ever experienced an odd displacement in which you found yourself inexplicably in a location different from where you remember being only seconds before and it was not the common "road hypnosis" while driving?

yes no If yes, please describe:

Have you ever dreamed of being in a hospital?

yes no If yes, please describe:

Have you ever dreamed about lying on a table?

yes no If yes, please describe:

Have you had any disturbing or realistic dreams about babies or small children?

yes no If yes, please describe:

Have you ever dreamed about UFOs?

yes no If yes, please describe:

Have you ever woken up paralyzed with a sense of a person, presence, or something else in the room?

yes no If yes, please describe:

Have you ever seen lights or balls of light in your room for which you have no explanation?

yes no If yes, please describe:

If you are a woman, have you ever had any unusual problems with pregnancy?

yes no If yes, please describe:

If you are a woman, have you ever felt certain that you were pregnant, but the pregnancy suddenly disappeared?

yes no If yes, please describe:

Have you ever felt that you were actually and inexplicably flying and it was not an out of body experience or a dream?

yes no If yes, please describe:

Do you have inexplicable fears about certain areas such as stretches of highway, open fields, rooms in a house, and so forth?

yes no If yes, please describe:

Have you actually left your body, or had an unwanted and\or unexpected out-of-body experience?

yes no If yes, please describe:

Has a deceased relative or friend ever visited you in your home at night?

yes no If yes, please describe:

Have you ever seen or sensed the presence of a ghost?

yes no If yes, please describe:

Have you ever had a religious vision or visitation?

yes no If yes, please describe:

Have you ever awakened wearing clothes that were not yours and you do not know how you got them, and/or have you ever awakened with your clothes on in the wrong way or not on at all when you had put them on correctly?

yes no If yes, please describe:

Do you inexplicably feel that you are secretly teaching or helping someone?

yes no If yes, please describe:

As an adult, do you feel you have a special influential or controlling person outside of your normal life whom no one knows about and who is not a religious figure?

yes no If yes, please describe:

(Sorry, I'm required to ask the following two questions. These questions deal with how one copes with unusual events rather than whether one has invented them.)

Have you ever been hospitalized for psychiatric or psychological disorders?

yes no

Are you on medication for emotional or psychological problems?

yes no

Please use this area to describe the unusual events in your life that this questionnaire has not covered.

Have you ever worked with a UFO abduction researcher?

yes no

Name of researcher:

Please describe the nature and extent of your work with the researcher:

How did you find out about this web site?

What has led you to fill out this questionnaire?

 

         

   
 
All content © David M. Jacobs and International Center for Abduction Research except as noted.