| Please describe your current profession: |
| Are you presently in a relationship? |
Yes
No |
| If not, would you like to be in one? |
Yes
No
Maybe |
If you are presently in a relationship,
what motivates you to remain in it?
(Please check all that apply.) |
Enjoy each other's company
Allows me my personal time
Non-Judgmental
Physical
Energetic
Thoughtful/Affectionate
Offers interesting challenges
Remains the same
Marriage
Other
|
Have Mutual Interest
Unconditional Acceptance
Fun to be around
Sense of Humor
Adds dimension to my being
Uncomplicated
No expectations
Do things together
Similar interests
|
If you are not presently in a relationship,
what would motivate you to initiate one?
(Please check all that apply.) |
Enjoy each other's company
Allows me my personal time
Non-Judgmental
Physical
Energetic
Thoughtful/Affectionate
Offers interesting challenges
Remains the same
Marriage
Other
|
Have Mutual Interest
Unconditional Acceptance
Fun to be around
Sense of Humor
Adds dimension to my being
Uncomplicated
No expectations
Do things together
Similar interests
|
What are the 3 most important qualities
you look for in a successful relationship? |
|
| What are the 3-5 most major obstacles in dating over 50? |
|
| Would yo u marry again? |
Yes
No
Maybe |
| What are your 3-5 reasons why? |
|
| What are 3 qualities of a successful marriage? |
|
What 3-5 qualities/characteristics do you feel
men want out of a relationship? |
|
What 3-5 qualities/characteristics do you feel
women want out of a relationship? |
|
| What 3-5 attributes describe what men want in a marriage? |
|
| What 3-5 attributes describe what women want in a marriage? |
|
| Thinking about communications between men and women, what attributes are most important to you for effective communication? |
|
Please tell us about yourself. |
| Gender: |
Male
Female |
| Occupation: |
|
| Age: |
50-55
56-60
61-65
66-70
70+ |
| Times Divorced: |
0
1
2
3
4
5+ |
| How many years has it been since you last divorced? |
0-1
2-3
4-5
6-7
8+ |
| Education: |
|
Number of children over the age of 21: |
|
| Annual Income:: |
|
Less than $30,000 |
$60,001 - $75,000 |
|
$30,001 - $45,000 |
$75,001 - $90,000 |
|
$45,001 - $60,000 |
Over $90,000 |
|
| Are both of your parents still living? |
Yes
No |
| If yes, what are their ages? |
Mother,
Father,
|
| If no, which parent is still living? |
Mother
Father |
| My relationship preference is: |
Heterogeneous
Homogenous
Both |
What type of recreational activities are you involved in?
(Please check all that apply.) |
Walking
Jogging
Music
Traveling
Theatre
Cultural Events
Dancing
Camping
Other
|
Equestrian
Biking
Fine Dining
Bowling
Golf
Tennis
Fitness Clubs
Hiking
|
| How often do you travel for business? |
Never
1/Month
2/Month
3/Month
More than 3x/Month |
Again we both thank you for taking your time and energy to complete this survey.
If you would like to be a participant in our focus group, please give us your contact information: |
| Name: |
|
| E-Mail Address: |
|
| Address: |
|
| City: |
State:
|
| Zip |
|
| Phone: |
(xxx) xxx-xxxx |
