Exceptional Experiences and Near-Death Experiences Questionnaire


If you would like to participate in current research, you can fill out the following questionnaire. It doesn't matter whether or not you have had any exceptional experiences for your responses to be a valuable addition to this survey, nor does it matter whether you have been near death or not. All responses are important.

You may send us your questionnaire online or by regular mail. For regular mail, print the web page, fill it out and mail it to:

William Roll, Ph.D.
Department of Psychology
State University of West Georgia
Carrollton, Georgia  30118

If you prefer to complete the questionnaire online, simply answer all of the questions below that pertain to you, then click the Send Questionnaire button at the end of the questionnaire.

Name:

Email:

Address:

City/Town:

State/Province:

Zip/Postal Code:

Country:

Work Phone (optional):

Home Phone (optional):

Age:

Sex: Male Female

Have you filled out this questionnaire before?: Yes  No


1. How often do you remember your dreams?

Almost never, few times in life
Less than once a month
About once a month
About twice a month
About once a week
About 3 times a week
Always, almost every night
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2
3
4
5
6
7


2. How would you describe your dreams on the following scale?

Logical, realistic,
ordinary, as if awake
  Chaotic, bizarre,
disconnected
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2
3
4
5
6
7


3. Have you ever had an experience of yourself or your surroundings that was seemingly real (not a dream) but totally unlike the way you commonly experience things?

Never  Once  2 or 3 times  4 or more times

If you have ever had such an experience, please describe one such experience:


4. Have you ever been aware of actual things that were happening beyond the reach of your familiar senses and that you could not know about by normal means?

Never  Once  2 or 3 times  4 or more times


5. Have you ever been aware of things in the future that you could not have known about?

Never  Once  2 or 3 times  4 or more times


6. Have you ever had the experience of leaving your body and of observing things from another place?

Never  Once  2 or 3 times  4 or more times


7. Have you ever sensed the presence of a deceased person?

Never  Once  2 or 3 times  4 or more times



There are two physiological conditions that may be related to unusual cognitive abilities. One is associated with the hypersensitivity that may bring on asthma and allergies, the other with vasopressin, the hormone whose most familiar effect is water-retention in body tissue.


8. Have you ever had asthma or allergies?

Yes  No

If you answered yes, briefly describe the nature, frequency and severity of your symptoms:


9. Do you now have asthma or allergies?

Yes  No


10. Have you ever experienced water retention that is not caused by poor circulation, excess salt intake, (or your monthly cycle if you are a woman)?

Yes  No

If you answered yes, briefly describe the part(s) of the body affected, the frequency, and the severity of your symptoms:


11. Do you presently experience water retention that is not caused by poor circulation, excess salt intake, (or your monthly cycle if you are a woman)?

Yes  No


12. Have you ever been present at the moment when someone has died?

Never  Once  2 or 3 times  4 or more times


Skip this question if you have never been present at the moment when someone has died.
13. If you have ever been present when someone died, have you ever sensed or ever felt anything unusual when the person died?

Never  Once  2 or 3 times  4 or more times

If you have ever sensed or felt something unusual when someone has died in your presence, please describe one of these experiences:


14. Have you ever had an unusual sensation, perception, or feeling when someone you knew died unexpectedly in a distant place and you had no normal way of knowing about it?

Never  Once  2 or 3 times  4 or more times

If you have ever had an unusual sensation, perception, or feeling when someone you knew died unexpectedly and you had no normal way of knowing about it, please describe one of these experiences:


15. Have you ever been close to death?

Never  Once  2 or 3 times  4 or more times


Skip this question if you have never been close to death.
16. What has brought you close to death? (Check all that apply)

Heart-attack Other illness
Car Accident Other accident
Gun-shot wound Other attack
Suicide attempt Other cause (please explain):


17. Have you ever been close to death and at that moment had an experience of yourself or your surroundings that was seemingly real but totally unlike the way you commonly experience things?

Yes  No



If you answered no to the preceding question, you have finished the questionnaire. You may send it now by clicking the "Send Questionnaire" button at the bottom of this page. Click to go there.

If you answered yes to the preceding question, you have had a near-death experience (NDE). Please continue with the questions below.



18. Please tell us about your near-death experience in as much detail as possible. If you have had more than one NDE, describe the most outstanding and use it for the questionnaire:


19. If you recall, please state the hour, date, and place of your near-death experience. If you don't know the exact hour, date, or place, and if you can recall, write the approximate time of day, approximate time of year, approximate year, approximate place:


20. Please indicate how important or meaningful your NDE was to you.

No Importance Great importance
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2
3
4
5
6
7
8
9
10


21. Please describe your emotions during the NDE:


22. During your NDE, were you aware of actual things that were happening beyond the reach of your familiar five senses and that you could not know about by normal means?

Yes  No


23. During your NDE, were you aware of things in the future that you could not have known about by normal means?

Yes  No


24. During your NDE, did you have the experience of leaving your body and of observing things from another place?

Yes  No


25. During your NDE, did you sense the presence of one or more deceased persons?

Yes  No


26. Since your near-death experience, have you been aware of actual things that were happening beyond the reach of your normal senses and that you could not know about by normal means?

Yes  No


27. If you answered yes to the preceding question, how does the frequency of such awareness since your NDE compare with the frequency of these experiences before your NDE?

Fewer  The same  More frequent


28. Since your near-death experience, have you been aware of things in the future that you could not have known about by normal means?

Yes  No


29. If you answered yes to the preceding question, how does the frequency of such awareness since your NDE compare with the frequency of these experiences before your NDE?

Fewer  The same  More frequent


30. Since your near-death experience, have you had the experience of leaving your body and of observing things from another place?

Yes  No


31. If you answered yes to the preceding question, how does the frequency of such awareness since your NDE compare with the frequency of these experiences before your NDE?

Fewer  The same  More frequent


32. Since your near-death experience, have you had the experience, when awake, of sensing the presence of a deceased person?

Yes  No


33. If you answered yes to the preceding question, how does the frequency of such awareness since your NDE compare with the frequency of these experiences before your NDE?

Fewer  The same  More frequent


34. Since the near-death experience, have you noticed any change in your relationship to other people?

Yes, I feel more remote from others

No, I feel the same toward others as I did before the experience

Yes, I feel more connected to others


35. Since the near-death experience, have you noticed any change in your relationship to your physical environment?

Yes, I feel more separated from things in my environment

No, I feel the same as I did before the experience

Yes, I feel more connected to things in my environment


36. Since your NDE, have you experienced any physical or medical changes?

Yes  No

If yes, please describe:



Thank you for filling out this questionnaire.