Age

Male

How long-

How Long

How Long

Female Heterosexually married

Children

Homosexually married

Previous such connections

Divorced.

Length of each.

Your Education: Grammar school:

High School

College

Degrees

Fields of specialization

Present Employment (type),

How Long -

Previous Employment (type).

How long

Do you rent

Own your own home

How long have you

How long at former address

lived there

To describe the economic status of those replying, what is your monthly

income.

Present state of your health.

Have you ever had serious illness

What

Have you ever been under a psychiatrist's or psychoanalyst's care

How long

Do you smoke

In what way-

In a mental institution

Has drinking ever been a problem

Are you active in homophile work

In Civic or Philanthropic work

How long

How long.

Which