| Name: | (You can use pseudonym if you prefer) |
| Email Address: | Required |
| Country: | |
| Religion: | (if applicable) |
| Race: | |
| Age: | |
| Length of Victimization: | years |
| Male or Female: | |
| Male: | |
| Female: |
| Level of Education: | |
| High School: | |
| Some College: | |
| College Graduate: |
| Military Background: | ||
| Yourself: | Yes | No |
| Your Parents: | Yes | No |
| Jobs and Job Descriptions | |
| Job: | Job Description: |
| Your Health: | |
| Poor | |
| Unknown | |
| Excellent |
| Do You: (Please check all that apply) | |
| Smoke Cigarettes | |
| Use Illegal Drugs |
Personality: (Please check one of the pair of adjectives that most describes you)
| Reserved | Outgoing | Predictable | Spontaneous | Follower | Leader | Fixed, Rigid | Open To New Ideas |
| Auditory (Please check all that apply) | |
| Voices | |
| Ringing in the Ears |
Other Auditory Effects (Please be as specific as possible)
| Visual (Please check all that apply) | |
| Illusions/Hallucinations | |
| Dream Manipulation | |
| Foggy/Hazy/Blurry Vison |
Other Visual Effects (Please be as specific as possible)
| Tactile (Please check all that apply) | |
| Tingling | |
| Numbness | |
| Pressure | |
| Heat/Cold | |
| Pain |
Other Tactile Effects (Please be as specific as possible)
| Smell (Please check all that apply) | |
| Foul Odors | |
| Loss of Smell | |
| Alteration of Smell |
Other Changes in Sense of Smell (Please be as specific as possible)
| Taste (Please check all that apply) | |
| Foul Tastes | |
| Loss of Taste | |
| Alteration of Taste |
Other Changes in Sense of Taste (Please be as specific as possible)
| Other (Please check all that apply) | |
| Sleep Deprivation | |
| Street Theater | |
| Interference With Electronic Equipment |
Other Effects (Please be as specific as possible)
| Hobbies and Interests: |
|
Please add any additional data or comments you might have:
Thank you. |