thank you for filling out this questionnaire. no remuneration will be given, but rest assured, your nameless, faceless answers will be shared with the entire world.
for each question, please choose the response that is most indicative of your present situation.
question 1: what is your relative level of isolation or socialization?
a1: i wandered lonely as a cloud
a2: the world is too much with us
a3: we are here as on a darkling plain
a4: i have known the eyes already, known them all
question 2: what are your current feelings or emotions toward death?
a1: i heard a fly buzz when i died
a2: i have measured out my life in coffee spoons
a3: rage, rage against the dying of the light
a4: what dreams may come when we have shuffled off this mortal coil must give us pause
question 3: how would you rate your current physical condition?
a1: i am large, i contain multitudes
a2: like a patient etherized upon a table
a3: i grow old … i grow old …
a4: some of us are out of breath/and all of us are fat!
question 4: how would you describe your prevailing emotional state?
a1: deep into that darkness peering, long i stood there wondering, fearing
a2: all day she sits upon the stair or on the steps or on the mat
a3: it brought/into his mind the turbid ebb and flow/of human misery
a4: i have eaten/the plums/that were in/the icebox
question 5: what are your current feelings toward those closest to you?
a1: you are certainly not the pine-scented air
a2: are you – nobody – too?
a3: i cling to you so that you cannot unloose me
a4: i do not think that they will sing to me
thank you for taking the time to complete this survey. a psychoanalyst will call you in the morning.