1) Your Name:
2) Your Address:
3) City:
4) State or Province:
5) Zip:
7) Phone Number:
8) Email Address:
9) How Many Occupants at Location:
10) Occupants Names and Ages:
11) Occupants Occupations:
12) Occupants Religious Beliefs:
13) Time of Occupancy at Location:
14) Age of Site:
15) How many Previous Owners if known:
16) History of Site(tradgedies, deaths,
previous complaints):
17) How Many Rooms at Site:
18) Has the Location been Blessed:
19) Has there been any Recent Remodeling:
20) Any Occupants on Medication:
21) Any Occupants using Illegal Drugs:
22) Any Occupants drink Alcohol Heavily:
23) Any Occupants interested in the Occult
(ouija, seances, psychics, spells):
24) Any Occupants currently seeing
Psychiatrist:
25) Have any Religous Clergy been Consulted:
26) Has there been any Media Involvement:
27) Have there been any othe Witnesses
besides the Occupants:
28) Have there been any odors (perfumes,
flowers, sulfer, excreetment):
29) Have there been any Sounds (footsteps,
knocks, banging):
30) Have there been any voices (whispers,
yelling, crying and speaking):
31) Has there been any movement of Objects:
32) Has there been any levitations:
33) Have there been any uncommon cold or hot
spots:
34) Have there been any problems with
electrical appliances (tv, lights, kitchen appliances, doorbells, etc):
35) Have there been any problems with
plumbing (leaks, flooding, sinks, toilet bowls):
36) Any Occupants having Nightmares or
Trouble Sleeping:
37) Have there been any Physical Attacks:
38) Are your Pets Affected:
39) When was the first Occurance of
Phenomena:
40) What was the Witnesses reaction during
Phenomena:
41) How Long was the Duration of the
Phenomena:
42) Who first Witnessed the Phenomena:
43) Were there any other Witnesses:
44) What Time was the first occurance of the
Phenomena:
45) How often does the Phenomena Occur:
46) Do the Occupants feel the Phenomena is
Threatening:
47) What do the Occupants believe is
happening (is it supernatural):
48) Do all the Occupants Agree on what is
happening:
All information provided here will be kept confidential and be
used for evaluation purposes only...
