1. I typically think about my own death. Please check one only.

Daily
Weekly
Monthly
Yearly
I try to think of something else .

2. When I do think about death, the following best describes my reaction ...
 Please check one only.

I get fearful but think about it anyway.
I get fearful and try to think about something else.
I think about it comfotrably since it is a fact of life.
I think about my priorities since time is limited.

3. Have you done any end-of-life planning?

Yes
No

4. If yes to 3 above, please check actions below you have taken if any:

I have a will
I have a living will (medical)
I have appointed a health care proxy.

5. (Answer only if you checked either of the first two boxes in question #2 above.)

 When I think of aging and dying, I would characterize fears I have as ...
 Rank each one that applies to you with a score of 1-4.
 Number 1 is the strongest fear...
 Number 4 is is the weakest fear.
 A score of "0" means this is not something you fear at all.

Please rank 0 1 2 3 4 I fear losing my identity at death.

Please rank 0 1 2 3 4 I fear the loss of control at death.

Please rank 0 1 2 3 4 I fear the loss of consciousness.

Please rank 0 1 2 3 4 I fear physical pain at time of death.

Please rank 0 1 2 3 4 I fear a possible judgement day after death.

Please rank 0 1 2 3 4 I fear there may be nothing more.

Please rank 0 1 2 3 4 I fear not being there for a loved one, child or spouse.

Use this space to describe any other fears you have related to dying:

6. How do you describe your religious beliefs? Please choose ONE only.

I am an atheist and don't believe in God.
I am an agnostic and not sure about God.
I believe in God.

7. If you indicated in question #4 above that you do believe in a God, how do you characterize your deity.

I believe in a God you can talk to.
I believe God is an energy, a force but not a human-styled figure.
I believe we merge with the universe at death and that is God.
I believe there is a heaven and a hell and God is in heaven and a Devil in hell.

8. Rank the following to indicate how you get answers to important personal questions.
 Number 1 is the highest, the most powerful source for your answers.
 Number 4 is is the least important source for you.
 A score of "0" means it is not at all an important source.

Please rank 0 1 2 3 4 When I pray in my Church, Mosque, Synagogue or other .

Please rank 0 1 2 3 4 When I talk to my spiritual leader - a priest, rabbi, guru or other.

Please rank 0 1 2 3 4 When I meditate by myself.

Please rank 0 1 2 3 4 From something I feel in my gut.

Please rank 0 1 2 3 4 From God when I ask my diety.

Please rank 0 1 2 3 4 From my own sense of self or my inner voice

Please rank 0 1 2 3 4 Mostly from friends or authorities

9. Please pick ONE of the following five statements that BEST characterizes your attitude about your environment. Choose only ONE please.

The world will take care of me
Life is a battle for survival
I can overcome problems and get what I want.
Hard work wins the day.
Our fate is pretty well predetermined.

10. As a child, can you remember how you first learned about death? Please tell us in space provided below.

11. When you were a child, did your parents (or other caregiver) have a talk with you specifically to explain death to you?

Yes.
No.

12. Have you ever had a "brush with death"? For example, perhaps you were nearly hit by car or you fell from a dangerous height or you had a serious illness. Did you have any incident that might be called a close call?

Yes.
No.

If you checked "yes", please briefly describe what happened and how it effected you.

13. If you could, would you want to know your date of death now?

Yes, I would like to know.
No, I don't want to know.

14. If you knew your date of death in advance, what might change? Choose one:

Choose one: I'd plan the rest of my life with my death date in mind. I'd want to tell my family so we could plan together. I would rethink my life priorities. I would take fewer risks to protect myself. I would take more risks I would value my time less. I would value my time more None of the above

Something else? Please tell us here:

15. Please tell us your age group:

Under 25.
26 to 35
36 to 55
Over 55

16. Please tell us your highest educational degree:

Self-educated, no degree.
High School diploma
College degree
Post graduate degree- Masters
Post graduate degree- PhD.

We do not ask for any personal identification with this questionnaire to insure your candor.  So please share your thoughts with us without concern. Your answers help our research and we thank you very much for helping us.