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Death Anxiety Project Main

Age?
Under 20
21-30
31-40
41-50
51-60
61+
Gender?
Male
Female
Non-binary
Prefer to not say
Race?
White or Caucasian
Black or African American
Hispanic or Latino
Asian or Asian American
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Other
Education Level - Select highest level attained
GED
High School Diploma
Associate Degree
Bachelor Degree
Master Degree
Trade/Certificate
Martial Status
Married
Single
Divorced
Widowed
Same Sex
Other
Do you have a fear of death?
What age were you the first time you experienced death?
Have you ever lost a close relative?
Have you ever experienced the death of a child?
Yes
No
Have you experienced a violent death?
Yes
No
Do you believe in some type of afterlife?
Have you experienced any emotional or physical pain from a loss?
Yes
No
Have you ever attended a funeral service?
Yes
No
Have you ever made funeral arrangements?
Yes
No
Mark which you prefer
Burial
Cremation
Burial of cremated remains
None
Do you worry about dying?
Yes
No
Does it bother you that you may die before you have done everything you wanted to do?
Yes
No
Do you worry that you may be alone when you are dying?
Yes
No
Do you worry that expenses connected with your death will affect other people?
Yes
No
Does it worry you that your instructions may or may not be carried out after you die?
Yes
No
Does the thought of leaving loved ones behind when you die upset you?
Yes
No
Do you worry that those you care about may try to forget you after your death?
Yes
No
Are you worried about not knowing what to expect after death?
Yes
No
Does the thought bother you that you may be a burden on family and friends leading up to your death?
Yes
No
Do you worry that you will be a burden to your friends and family after you die?
Yes
No
Do you worry that there is not an afterlife?
Yes
No
Are you religious?
Are you comfortable viewing the body at a funeral?
Yes
No
Do you find yourself avoiding certain activities because of your fear of death?
Yes
No
Do you worry about suffering or being in pain for a long time before you die?
Yes
No
Are you part of any organizations that you would include in your funeral?
Yes
No
Have you ever seen these organizations at a funeral service?
Knights of Columbus
Lion's Club
Elk's Club
AMVets
American Legion
No
Have you seen military honors performed at a funeral service?
Yes
No
Have you been to a religious funeral service?
Yes
No
What denominations have you experienced a funeral service for?
Catholic
Lutheran
Jewish
Amish/Mennonite
Buddhist
Protestant
Other
Do you have any wishes for your funeral?
Yes
No
Is your next of kin aware of your wishes to uphold them?
Yes
No
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