Please Fill out the Following Questionnaire with As Much Information As You Are Comfortable

Please fill out the following questionnaire with as much information as you are comfortable sharing. The more information I have, the more I can see underlying patterns. When you are finished, please email it to: or fax it to 651-452-8912.

Date: ______

Name: ______Age: ______Birth Date: ______Address:______

Occupation: ______

Telephone Number: (H): ______(W):______

Status: Single Married Partner Relationship Separated

Divorced Other: ______

Spouse/Partner: Name: ______

Birth Date: ______Age: ______

Occupation: ______

Length of Relationship: ______

Children: None How Many?: ______Your Partner/Spouse?

Names and Ages: ______
WHAT DO YOU CONSIDER TO BE THE MOST TENSION-PROVOKING PROBLEMS IN YOUR LIFE?

1.  At Home: ______
______

2.  In the Workplace: ______
______

3.  Relationships (e.g partner, parents, children, friends, etc) ______
______

4.  If you have dual family relationships where your partner has children from a previous relationship, does this present any problems for you? ______
______

II.  Mind / Body Assessment:
As you review the following symptoms take note of their occurrence and frequency. What are you feeling about having these symptoms? How would you describe them and what is going on in your life that may be contributing to your symptom/s? As you learn to listen to and trust the message your body sends, you will be taking an important step towards healing:

1.  Do you grind or clench your teeth? No Yes Length of time: ______When did this begin? ______
______
Do you tend to do this on similar occasions, eg at work, at home, at night? ______
______

2.  Are you aware of any pain or tight muscle in any part of your body other than your head? No Yes If yes, where? Arms Legs Back
Other: ______
______

3.  Do you have headaches? No Yes If no, proceed to question 13; if yes, what situations arise that create an “aching head”? ______

4.  How severe? Very Moderate Dull

5.  How long does a headache usually last? Less than 3 hours? Less than a day? Less than a week? Other: ______
______

6.  Describe your headache in your own words: ______
______

7.  Have you ever been bothered by your heart pounding very quickly? Yes No If yes, how often? ______
______

8.  Are your hands usually: Cold Warm Are they frequently sweaty? ______

9.  Are your legs usually: Cold Warm

10.  When you feel your hands or feet are cold ask yourself, what are you emotionally feeling?
Tense? Anxious? ______
______

11.  Describe any other physical conditions you are dealing with currently or have in the past (repeating illness, surgeries, conditions such as high blood pressure, constipation/diarrhea, pain, etc.) All physical issues, not just infertility, have mind-body links. By sharing these other conditions, I can see underlying patterns:
______

III.  EMOTIONAL / TENSION OVERVIEW

1.  Past Experience: Your Emotional Legacy
Please check the statements you feel apply to you:
When I was growing up I felt weird, different
I never felt I belonged anywhere
I felt angry but I never knew why
I was given enough material things, but was not understood
If I wanted to do something, I was always shot down
I always had to be perfect
I was blamed a lot for mistakes, whether mine or others
I could never express anger or love easily
I received a lot of verbal abuse
I received a lot of physical abuse
I never had someone to confide in

2.  Current Feelings and Attitudes

i.  Problems in life that I have trouble dealing with today are: ______
______

ii. I feel angry when (please check what is appropriate):
People don’t support me People seldom keep their promises I need to always be perfect other: ______
______

iii.  I never get angry at other, only at myself: ______
______

iv.  When I get angry I (check all that apply): Lose my temper Eat Smoke Drink
Get a headache Stomach Knots Become Nauseated Other: ______
______

v. Do you have any mental blocks? No Yes Check where appropriate:
Short Term Memory Losing Things Math Do other family members have these or other difficulties? ______
______

vi.  Do any of these mental blocks hinder you to the point that you feel incapacitated?
No Yes Please describe:______
______

vii.  Fears (check where appropriate): Going outside Closed Spaces Speaking
Elevators Insects or bugs Members of the opposite sex Traveling (eg driving or flying) Other: ______
Did you have any childhood experiences that might have triggered these fears? Who else in your family experiences these fears? Please explain: ______
______

viii.  Do you constantly feel under pressure or strain? Please describe: ______
______

ix.  Are you able to enjoy your normal everyday work activities? ______
______

x. Do you feel nervous and “Hung Up” all the time? Are there different life circumstances that seem to trigger these responses? Or increase these feelings? ______
______

xi.  Do you feel you have less energy than you used to and tire easily? What do you feel are your energy leaks? When do you experience these leaks? In other words, what is going in your life at that moment? ______
______

xii.  Do you have trouble making decisions? In what areas of your life? Who else in your family has difficulty with decision making? ______
______

xiii.  Do you often feel that you are taken advantage of? ______
______

xiv.  Do you find life a struggle most of the time? ______
______

xv.  Do you get scared or panicky for no apparent reason? ______
______

xvi.  Do you think of yourself as a worthless person? ______
______

xvii.  Do you feel life isn’t worth living? ______
______

IV.  LIFESTYLE REVIEW

1.  EATING

i.  How many cups of coffee or tea do you average per day?
zero 1 or 2 3 or 4 More

ii. How many 12 oz diet soda per day? Zero 1 – 2 3 – 4 More

iii.  Check time of day you usually have pastries or rolls : Breakfast Morning Break
Lunch Afternoon Break Dinner Evening Snack

iv.  When you are overeating, are you feeling depressed? Often Seldom Never

v. Do you crave certain food? ______What Kinds? ______
How often? ______
______

vi.  Let’s assume that you are “addicted” to a certain food. What food would it be?
None Candy Pastry Salty Foods Other: ______
______

vii.  How many pounds do you feel that you are overweight? ______

viii.  How many times have you lost and regained weight? ______

ix.  Are you on a nutritional program? No Yes

x. Do you have trouble concentrating? No Yes If yes, when? ______
Mid-morning Mid-Afternoon All the time
Only on special occasions (i.e. reading listening Other: ______)
______

2.  SMOKING

i.  Do you smoke? No Yes

ii. If yes, ½ pack per day 1 pack 2 packs More ______
Who smokes in your family? Have you tried to stop smoking?
______

3.  DRINKING

i.  Do you drink alcoholic beverages? No Sometimes Often
If sometimes or often, give frequency, type and quantity (e.g. three bottles of beer per week, six mixed drinks, etc.). Does drinking have some family meaning for you? What do you feel about alcoholism? ______
______

ii. Do you become intoxicated? No Yes How often? ______
______

iii.  Have you ever been arrested for drunken driving? No Yes

iv.  Does your drinking create problems in the workplace? No Yes
______

4.  SLEEPING

i.  Do you have trouble falling asleep? No Yes

ii. Do you have trouble staying asleep at night? No Yes

iii.  Do you awaken feeling well-rested? No Yes

iv.  Do you dream? No Yes

v. Is there a particular dream which keeps repeating itself? No Yes
If so, please describe ______
______

vi.  Are your dreams pleasant? Yes No Any nightmares? ______
Please describe: ______
______

vii.  Do you ever dream about babies or themes relating to babies, conception, pregnancy, or birth? No Yes Please explain ______
______

viii.  Do you keep a dream diary? No Yes

5.  RELAXATION / MEDITATION
Do you engage in any relaxation or meditation processes? No Yes
Please explain: ______
______

6.  PLANT GROWER / GARDENER
Do you have plants? Are they cared for by you? Do you consider yourself having a ‘green’ thumb? Do you enjoy caring for them? What do you feel like when a plant dies? ______
______

7.  ANIMAL / BIRD RELATIONSHIP
Do you have a relationship with an animal, bird, fish, etc. that you love, nurture and care for? What does this relationship mean to you? Did you have an animal relationship as you were growing up? ______
______

8.  PLAY
What does play mean to you? What part of your life do you consider to be play? Is your play truly lighthearted, joyous, and carefree? Can you play, both alone and with other people, in a way that renews, relaxes, and makes you feel good about being alive? ______
______

9.  PHYSICAL EXERCISE
List types of physical exercise and frequency: ______
______
How do you feel when you exercise? When you don’t? Who was active in your family? What was not? ______
______

V.  SEXUAL LIFESTYLE

1.  What is the average number of times per week that you engage in sexual activity?
______

2.  Are you satisfied with your sex life? No Yes Please explain: ______
______
If not satisfied, do you blame your mate, or do you take responsibility for helping to change your relationship so that it is fulfilling for both of you? ______
______

3.  Do you enjoy sex? ______
______

4.  How do you feel about your body? ______
______

5.  Are you comfortable with members of the opposite sex and how do you relate to them? Please comment: ______
______

6.  Are you comfortable with members of the same sex and how do you relate to them? Please comment: ______
______

7.  How do you feel about your relationship with your spouse or partner? Please comment : ______
______

8.  Do you feel you give and receive love easily or is it an effort? ______
______

VI.  REPRODUCTIVE HISTORY

1.  Menstrual History (if applicable)
Onset of menses: Age ______
Is your cycle currently: Regular Irregular Please describe: ______
______
Painful? No Yes
What did you hear about menstruation from your mother/grandmother? Who first told you about it? When did you first hear about it? Thank about this question and answer it carefully. Your response will indicate how and what you learned about your initiation into womanhood: sexuality, pregnancy, boys, etc. ______
______

2.  Have you experienced any sexual trauma or abuse? No Yes

3.  Have you or your partner had any abortions? No Yes How Many ______
Your Age What was going on in your life at that time
______
______
______
______
______
______
Were you able to tell your mother? Father? If no, why not? How do you feel about this? Have you ever participated in a grief ceremony about this abortion/s?______
______

4.  Have you or your mate had any miscarriages? (or stillbirths) No Yes
How many? ______
Dates What was going on in your life at that time?
______
______
______
______
______
______

5.  Death of baby/ies? No Yes
If yes, what are you feeling? ______
______

6.  Why do I want a baby? ______
______

7.  Why I don’t want a baby? ______
______

8.  Medical Treatment

i.  Have you consulted an MD for issues of fertility? No Yes

ii. If you have consulted a medical fertility specialist, what was the diagnosis? What are your feelings about the diagnosis? What was the language he or she used to describe your “problem”? What are your feelings in response? ______
______

iii.  Did you have any tests and/or medical treatment? No Yes
Please detail:
Date Procedure Results
______
______
______
______
______
______

iv.  Were you given any medication? No Yes If yes, what type? ______
______
Any reactions? ______
______

9.  Alternative health care (acupuncture, chiropractic, vitamin supplements)?
______

10.  What are your plans for upcoming cycles? (e.g. continuing to try naturally, planning an IVF, currently in the middle of a medicated cycle)______
______
______

VII.  ATTITUDINAL QUESTIONNAIRE: Please use extra sheets to record your responses if needed
The following questions are offered as an opportunity to stimulate your thoughts and feelings about you, your family history, your birth and its impact on you today. As you read the questions and respond be aware of any reactions you maybe experiencing in your body.

1.  Given the importance of in utero experiences, were you told what your parents’ life was like when your mother was pregnant with you?
______

2.  Was your mother working at the time of your conception? How old was she? Did she continue or stop working after your birth? Was it work she enjoyed? Did her work represent the fulfillment of her life’s dream? What did she tell you about her work? Did your birth change your mother’s life? What has she told you about this? What feeling does this evoke in you? ______

3.  At what age did your grandmother conceive your mother? Were you told what your mother’s birth was like? ______
______

4.  Specifically what did you hear about your birth? From which parent? Do the stories differ between your mother’s and father’s version? ______
______

5.  As you were growing up did you hear negative stories about pregnancy or childbirth from your parents? Grandparents? Aunts? Uncles? ______
______

6.  How does your family view working women and motherhood? ______
______

7.  What did your mother tell you about her experiences conceiving, carrying, and delivering your siblings? ______
______

8.  Do you feel children were valued by your mother? Father? Grandparents? Siblings? Do you feel you feel you were valued? ______
______

9.  Do your aunts and unless have children? What is their history of childbirth? Is these any history of problems with fertility or miscarriages? What about your cousins? ______
______

10.  Are you being pressured to have a child? No Yes By whom? How do you feel about this? ______
______

11.  Are many of your major life decisions based upon whether your parents would approve? ______
______