UK Synaesthesia Association
questionnaire

Tell us about your synaesthesia

It would help us tremendously if you would fill in this questionnaire which asks for some basic details about yourself and your synaesthesia. It should take about 5 minutes.

This information will then be added to our database and you will receive notification that it has been received. If you are unsure as to whether your experiences are synaesthetic or not then please feel free to contact one of our current synaesthesia researchers who may be willing to advise you. To withdraw your name from the database email us.

If you would prefer to fill in a paper version click here for the .pdf version or here for the Word.doc version (which can be edited on screen).

Many thanks for your time!

Note: You may tab between fields but please 'click' to make your button or box choices; hitting 'return' will submit the form.

PERSONAL INFORMATION

First Name: Middle Initial:
Last Name:

Date of Birth: (DD/MM/YYYY): Sex: M F

E-Mail Address:

House & Street Address:

Town or City:
Postcode:


Please select the geographical area which best describes where you live:

Handedness: i.e. which hand do you use for the majority of activities?

LEFT RIGHT

PLEASE MAKE SURE YOU TELL US MORE ABOUT YOUR SYNAESTHESIA BY ANSWERING THE QUESTIONS BELOW


ABOUT YOUR SYNAESTHESIA


To the best of your knowledge, have you always had synaesthesia?
Yes
No

Do letters of the alphabet trigger any synaesthetic sensations?
Yes
No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Smell Touch Pain Sounds
Shapes
Music Movement


Do English words trigger any synaesthetic sensations?
Yes
No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Smell Touch Pain Sound
Shapes
Music Movement

What has the LARGEST influence on the OVERALL COLOUR of a word?

First letter First sound Strongest vowel Meaning Loudness
Other (e.g. each letter has its own colour)

Are your synaesthetic sensations stronger when:
Read Heard No difference


Do numbers trigger any synaesthetic sensations? Yes No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Smell Touch Pain Sound
Shapes
Music Movement


Do days of the week/months of the year trigger any synaesthetic sensations? Yes No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Smell Touch Pain Sound
Shapes
Music Movement


Do voices trigger any synaesthetic sensations?
Yes
No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Smell Touch Pain
Shapes Movement


Does instrumental music trigger any synaesthetic sensations?
Yes
No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Smell Touch Pain
Shapes Movement

What has the LARGEST influence on the COLOUR of a musical note?

Pitch Instrument Loudness Don't Know

What has the LARGEST influence on the OVERALL COLOUR of a SERIES of notes?

Pitch Instrument Tempo (speed) Loudness
Don't Know


Does hearing sounds (e.g. dog barking; rain) trigger any synaesthetic sensations? Yes No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Smell Touch Pain Shapes
Movement


Do smells trigger any synaesthetic sensations? Yes No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Taste Touch Pain Sound Shapes
Music Movement


Does touch trigger any synaesthetic sensations? Yes No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes TastePain Sound Shapes
Music Movement


Do tastes trigger any synaesthetic sensations? Yes No

If you answered YES to the above question, please select ALL that apply:

Colour Shapes Smell Touch Pain Sounds Shapes
Music Movement


Does colour trigger any synaesthetic sensations? Yes No

If you answered YES to the above question, please select ALL that apply:

Shapes Taste Smell Touch Pain Sounds Shapes
Music Movement


Do these sensations appear to be:

External (outside your body, i.e. on the page, in the air)?
On your body surface: (i.e. skin, tongue, nostrils)?
Inside your body?
Appear as thoughts not sensations
Appear in Mind's Eye?
Some combination of the above?
Elsewhere? please state:


ABOUT YOU AND YOUR FAMILY


Are you a twin?: No Yes (non identical) Yes (identical)

If you answered YES does your twin also have synaesthesia?
YES
NO DON'T KNOW


Do any other members of your family have synaesthesia?
YES NO DON'T KNOW

If YES, please tick ALL that apply:

Mother Father Daughter Son Sister Brother
Maternal Aunt Maternal Uncle Paternal Aunt Paternal Uncle

Other: please state relationship to you:


Is there anything else you would like to tell us about your synaesthesia?:

 

By clicking the 'submit' button I understand that my personal information will be sent by email to the UK Synaesthesia Association where it will be held on record.

The UK Synaesthesia Association will not pass on any personal details to a third party without gaining my prior consent. I may withdraw from research participation at any time by emailing the UKSA to remove me from the database

 

Please download the application form and standing order mandate in .pdf format here or in Word.doc format here.

The Word.doc can be edited on screen before printing.