Hello! Thank you for taking the time to fill out this questionnaire! I am conducting this survey to help determine the accuracy of Numerological divination. In other words, I am determining whether or not Numerology is a crock. Results, once published, will be sent to you if you would like.

Section One: Personal Data

Name at Birth: ___________________________

Date of Birth: ____________________

name you introduce yourself as : ___________________________
(Hi, I'm Bob Smith)

Section Two: Ideals & Characteristics

Please Check the characteristics that mean the most to you:

  1. ___Self-Confidence, Leadership

  2. ___Balance, Diplomacy, Peace

  3. ___Self-Expression, friends, parties

  4. ___Hard Work, Loyalty

  5. ___Freedom, Variety

  6. ___Love, Family, Nurturing, Helping Others (friends&family)

  7. ___Thought, Wisdom, Time Alone

  8. ___Power, Money & Success

  9. ___Wisdom, Altruism, Helping Others (worldwide)

Now Please circle your favorite numbers:

12345
6789
Do you have any other favorite number(s)?
Please put it or them right here: __________________________

Do you want to find out about the results of this survey? ___Yes ___No

Thanks!