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* 1. What is your age?

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* 2. What is your gender?

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* 3. What is your disability?

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* 4. How old were you at the onset of your disability?

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* 5. Did you date before you were disabled?

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* 6. How many dates have you been on in the last year?

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* 7. How do you find dates?

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* 8. Briefly describe a recent date that was particularly good or bad.

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* 9. We’re interested in honest stories about the highs and lows of dating with a disability. Would you be willing to be candidly interviewed for a story on dating and to have your story published?

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