Confidential Questionnaire

Part I - About Yourself

First Name:

Middle Initial:

Last Name:


Male     Female

Date of Birth:





Zip Code:


Cell Phone:


Best way to contact you:

Phone     E-Mail


Weight (lbs):

Hair Color:

Eye Color:

How many piercings do you have, if any?

How many tattoos do you have, if any?

How would you honestly describe your physical appearance?

Describe your occupation:

Annual Income:


Approximately what percent Chaldean would you say you are?

If you are not Chaldean or if you are any other ethnicity in addition to Chaldean, please explain.

What village in Iraq do you descend from, or are you unsure?

What role does religion play in your life?

Have you previously been married?

Do you have any children? If so, how many?

Do you want to have children in the future?

How do you feel about pets?

What kind of music do you enjoy?

What activities or hobbies do you enjoy? Please be specific.

What groups or organizations are you involved in, if any?

How often do you smoke?

Comment on smoking:


Check any of the following that apply to you:

I am new to the area

I am dating someone not compatible

I am passive or shy

I am an open book

I am ready to get married in the near future

I am not ready for marriage

It takes a while to get to know me

I'm really busy with work and do not have much time to meet other singles

I meet a lot of people, just not the right type

When involved with someone, I generally tell him/her just about everything

I do not feel comfortable asking people out

I try not to be too open because I don’t want to get hurt

I find it easy to get emotionally close to people

I sometimes find it difficult to trust people I may date

I tend to get bored with relationships over time

I enjoy quiet evenings at home

I enjoy trying new things

I enjoy nights out on the town

I have been set up on blind dates in the past


Any other comments about yourself:


Part II - Your Match


Age range compared to your age:

Height Range:

How important is your match’s height?

Weight Range:

Hair Color:

Hair Style/Length:

How important is it that your match be physically attractive?

How would you feel if your match has piercings?

How would you feel if your match has tattoos?

Any physical turn-offs:

Does it matter what kind of music your match listens to?

How important is your match’s education to you?

How important is your match’s income to you?

How important is your match's religion or spirituality to you?

Does it matter what percent Chaldean your match is?

Does it matter what village in Iraq your match descends from? If yes, please specify.

Does it matter if your match has been married?

Would you consider marrying a non-Chaldean? If so, what other ethnicities would you be willing to accept as matches?

Does it matter if your match has a pet?

How important is it where your match lives?

(For example, would you be willing to meet a Chaldean match from another state?)

Please indicate the most that you would accept your match to smoke:

What are three turn-offs you have with a potential partner?

Any other comments about your ideal match:


How did you hear about MATCHaldean?

Online Advertisement or Search
Newspaper or Magazine
Flyer or Brochure
Word of mouth


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