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 Name
Last Name
Age
*
Birthdate
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
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?
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Other relevant degrees or certificates?
*
Brief description of your profession?
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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?
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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.
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Describe your relationship with your father?
*
Do you have children? If so, what are their ages?
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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?
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Would you describe yourself as religious or spiritual?
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Political views.
*
How often do you drink?
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Drink of choice.
*
Do you smoke?
*
Do you have pets? If yes, what kind?
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Are you open to having pets? If yes, what kind?
*
For your first date, do you prefer drinks or dinner?
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What is your greatest accomplishment in life?
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Five things you can't live without.
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Favorite book.
*
Favorite movie or tv show.
*
Dinner party guests? ( Any five people, living or dead)
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Do you "eat to live" or "live to eat"?
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If you could be in any country, where would you be and why?
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Where do you see yourself romantically in three years?
*
Which of the following would you consider dealbreakers in a relationship?
*
Dishonesty
Lack of commitment
Disrespect
Different lifestyle values (health, faith, etc.)
Lack of ambition
Other
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