SOURCE PROCESS BREATHWORK

BIRTH PROFILE
(Confidential)
 

ABOUT YOU:

NAME:

DATE:

ADDRESS:

POST CODE:

TELEPHONE Home:

Work:

Mobile:

EMAIL:

OCCUPATION:

BIRTHDATE:

Previous breathwork experience? Yes/No

Number of sessions?

With whom?

Any comments?

Are you taking medication? Yes/No

If so, what?

Do you have any psychiatric history? Yes/No

Please describe:

ABOUT YOUR BIRTH: (please circle as applicable)

Were you born in hospital/home/other?

Were you in an incubator?

Regular (head down)/Breech/Posterior/Caesarean/Forceps?

Was your cord around the neck?

Were you Premature/Overdue? By how much?

Was your mother anaesthetised?

Any other drugs?

How long was your mother in labour?

Male Doctor/Female Doctor/Midwife/Other?

Father's participation: In labour/In delivery/Niether

If not, how long before you saw him?

Separation from mother at birth?

How long?

How old was your mother at the time of your birth?

Were you breast fed?

For how long?

How old was your father at the time of your birth?

What number child are you in the family?

Age and gender of other siblings?

Are there any particular stories that you have heard from your family regarding your birth?

Have you ever had an abortion?

If so, how many?

When?

Is your mother alive?

Is your father alive?

ADDITIONAL QUESTIONS
 

Were you wanted/planned?

By both parents?

Did your parents want a boy or a girl?

If you had siblings, how did they feel about your arrival?

Did your mother have any stillborn births/miscarriages/infant deaths before your birth?

If so, please describe circumstances:

Were there any deaths in your family during your childhood?

If so, please describe relationship to you and circumstances:

Did you have any illnesses in infancy?

In later childhood?

Any accidents or injuries as a child?

Emotional traumas as a child?

Using four or five words or phrases, describe yourself as a child:

Did your parents divorce? Yes/No

If so, at what age?

Using four or five words or phrases, describe your mother (start with what you least like):

Using four or five words or phrases, describe your father (start with what you least like):

Describe your parents relationship whilst you were growing up:

Did you have any substitute parents whilst you were growing up?

Are you married/living with someone right now? Yes/No

If so, describe your partner:

Are you experiencing any significant problems in this relationship?

Are you having any problems with your body?

What is your most negative thought about yourself?

Do you have any negative thoughts about breathing?

Thank you very much for your participation.
ALL INFORMATION IS CONFIDENTIAL