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General Info Collection Form for New Cases
This questionnaire is a resource for experiencers to report their grid mark occurrence along with any relevant information in a methodical, experiencer-friendly way. If you need assistance or have questions, contact Jennifer via email:
experientialdreaming@gmail.com
. Please view our dossier ebook for statistical analyses and conclusions through the website home
experientialdreaming.com
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Date of First Contact with Our Team
MM
/
DD
/
YYYY
Time
:
AM
PM
Method of First Contact with Our Team
Blogger Contact Form
Comment
Direct Email
This Survey
Other:
Clear selection
Name
Your answer
Email Address
Your answer
Age
Your answer
Sex
Male
Female
Other:
Clear selection
Occupation
Your answer
Educational Background
Your answer
Interests/Hobbies/Passions
Identify anything person may be into
Your answer
World Location
Your answer
State of Health
Illnesses, Diagnoses, Medications, Physical fitness
Your answer
Grid Mark Location
Identify part of body upon which the mark site lay
Your answer
When was the Mark Discovered?
Include Date/Time
Your answer
Date of Actual Occurrence
MM
/
DD
/
YYYY
Estimated Time of Actual Occurrence
(Night, day, between the hours of...)
Your answer
In what position were you [sleeping] when it appeared?
Left Side
Right Side
Stomach
Back
Other:
Clear selection
Who 1st noticed the mark on your body?
Myself
Significant Other
Son/Daughter
Relative
Friend
Co-worker
Random Stranger
Other:
Clear selection
Mark Appearance Details
(general shape, dimensions, # of rows, # of dots, indentation, scoops, grooves)
Your answer
Sensation at Site
Minimal to Moderate Pain/Discomfort
Moderate to Severe Pain/Discomfort
Chronic Pain
Burning or Heat
Pinching or Poking
Pressure
Tugging or Pulling
Itchiness
Swelling
Aggravated skin
Blisters, scabs, or puss present
Bruising (tender to touch)
No pain, no sensation
Other:
Activity
What were you doing at the time of the mark's appearance?
Your answer
Any unusual dreams, events, or happenings around time of appearance?
Please describe in as much detail as you can any events or info you deem relevant.
Your answer
Predisposition to Dreams/OBE's/Altered State Memories
How common is it for you to recall unusual dreams or the like?
Not very common
Sometimes
Somewhat often
Often
Very Often
All the time
Clear selection
Duration
Estimate Length of Time Before Mark Disappeared
Your answer
Blood Type
Include Letter(s) and whether positive or negative (i.e.: O+)
Your answer
Religious/Spiritual Beliefs
General description or Denomination
Your answer
Personality Profile
Choose some adjectives to describe yourself
Your answer
AND/OR
Mark all that apply
Nature Lover
Skeptical
Curious
Open-minded
Devout
Empathic
Introverted
Extroverted
Compassionate
Creative
Other:
Possible Causes and Factors
List any guesses or intuitions as to what caused your marks to appear.
Your answer
Experience/History with Strange Phenomena
Have you encountered any strange phenomena in your life before that may relate to your grid mark occurrence? Please summarize below.
Your answer
Additional Info
Please identify any additional details that may factor in to our investigation of your case.
Your answer
Do we have your permission to post a report about your case on our website?
(Only verified posts with sufficient information will be written for publication on the site)
Yes
Maybe
No
Clear selection
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