Lasting Chemistry Client Questionnaire Form

Lasting Chemistry Client Questionnaire

Please answer all questions to the best of your ability. If question does not apply to you, please enter N/A.
Name*

First NameLast Name
Age*
Birthdate*

MonthDayYear
Date
Phone Number*
Email*
example@example.com
Where are you located? City & State.*
Social Media Handles*
How did you hear about us?*
Height *
Hair Color*
Eye Color*
Body Type*
Are you physically active? Do you Participate in sports or physical activities? If so, how often?*
Do you have any dietary restrictions?*
What would you consider your most valuable attribute?*
What do you like to do in your free time?*
Did you attend college? If so, where and what year did you graduate?*
Other relevant degrees or certificates?*
Brief description of your profession?*
Ethnicities that best describe you? *
Marital Status *
Do you have siblings? If so, how many? What number child are you?*
Where did you grow up?*
Favorite places to visit? (i.e cities, nature spots, etc.)*
Countries you've visited?*
Do you hold citizenship in any other country?*
Are you parents still married? If not, how old were you when they divorced? Did they remarry?*
Describe your relationship with your mother.*
Describe your relationship with your father?*
Do you have children? If so, what are their ages?*
Do you want to have children in the future?*
How important is giving birth to your own children? (Scale of 1-10, 10 being the most important)*
What is your faith or religious affiliation?*
Would you describe yourself as religious or spiritual? *
Political views. *
How often do you drink?*
Drink of choice.*
Do you smoke?*
Do you have pets? If yes, what kind?*
Are you open to having pets? If yes, what kind?*
For your first date, do you prefer drinks or dinner?*
What is your greatest accomplishment in life?*
Five things you can't live without. *
Favorite book.*
Favorite movie or tv show.*
Dinner party guests? ( Any five people, living or dead)*
Do you "eat to live" or "live to eat"?*
If you could be in any country, where would you be and why?*
Where do you see yourself romantically in three years?*
Which of the following would you consider dealbreakers in a relationship?*

DishonestyLack of commitmentDisrespectDifferent lifestyle values (health, faith, etc.)Lack of ambitionOther
Should be Empty: