Somatic Repatterning Workshop
Lumen Natura

About Lumen Natura

Birth History Form

All questions are required fields. If you are uncomfortable answering any of them, please indicate this as your answer and contact me to discuss the question. If you prefer to print the form, fill it out and send it to me please contact me and I will email you a pdf.

PERSONAL INFORMATION








INTENTION AND PROFESSION





HEALTH HISTORY

Note: Many of the following questions are intensely personal. Your responses will be kept completely confidential. Do your best to fill the form out as completely as you can. Filling out this form begins the work of preparing your body to begin re-patterning your early imprints. If you have trouble with any of the questions please contact me directly to discuss this.












YOUR BIRTH AND CHILDHOOD


was an unmedicated vaginal birth at homewas an unmedicated vaginal birth in the hospitalwas a vaginal birth with anesthesiawas a vaginal birth with forcepswas a vaginal birth with cranial suction (vacuum extractor)involved a fetal heart monitorwas a Cesarean Section Birthwas a Breech birthwas a multiple birth - twin, triplet. (Did they live? Answer in the space below.)was premature (By how many weeks? Answer in the space below.)was followed by a stay in the neonatal intensive care unit (For how long, for what issue? Answer in the space below.)was followed by incubation (For how long and for what reason? Please answer in the space below.)









YOUR CHILDREN AND BIRTH EXPERIENCES



AGREEMENTS AND CONSENT