Exceptional Experiences and Near-Death Experiences Questionnaire
The ASPR’s historical questionnaire about exceptional experiences and near-death experiences. Preserved for reference; the form is no longer active.
Preserved text
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.
Please 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
1 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
1
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
1
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.
Source: archived ASPR page, /question.htm. The text has been reformatted for reading; obsolete navigation and form controls have been removed.