(2) If you entertain any fear of death at all, is the cause of it (A) prospect of bodily suffering only, (B) dread of the unknown, (C) idea of loneliness and separation from friends, or (D) in addition to all or any of these, a peculiar horror of an indescribable kind?
(3) Is the state of your belief with regard to a future life that of (A) virtual conviction that there is a future life, (B) suspended judgment inclining towards such belief, (C) suspended judgment inclining against such belief, or (D) virtual conviction that there is no such life?
(4) Is your religious belief, if any, (A) of a vivid order, or (B) without much practical influence on your life and conduct?
(5) Is your temperament naturally of (A) a courageous or (B) of a timid order as regards the prospect of bodily pain or mental distress?
(6) More generally, do you regard your own disposition as (A) strong, determined, and self-reliant; (B) nervous, shrinking, and despondent; or (C) medium in this respect?
(7) Should you say that in your character the intellectual or the emotional predominates? Does your intellect incline to abstract or concrete ways of thought? Is it theoretical, practical, or both? Are your emotions of the tender or heroic order, or both? Are your tastes in any way artistic, and, if so, in what way, and with what strength?
(8) What is your age or occupation? Can you trace any change in your feelings with regard to death as having taken place during the course of your life?
(9) If ever you have been in danger of death, what were the circumstances, and what your feelings?
(10) Remarks.