BiB Questionnaire

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Birth into Being Australia

Welcome and thank you for deciding to journey with us in our upcoming Birth into Being workshop. All questions are optional though the more information you can provide pre-workshop, the better we can cater to your needs. All information remains strictly confidential.

Questionnaire

* Indicates required field

Name *

First

Last

Email *

How did you find out about Birth into Being workshops / sessions? *

What is your main motivation / intention for joining this workshop? *

How many days of workshop are you planning to attend? *

Saturday Weekend

On a scale of zero to ten how are you feeling today? *

On a scale of zero to ten how would you rate your usual outlook on life? *

How were you born? *

premature on time late vaginally unassisted assisted (forceps/vaccum) don't know

Notes (anything you’d like to share about your birth?) *

Were you adopted? *

Yes No dont know

Age? *

Were you breastfed? *

Yes No dont know

How long for? *

How many times have you been pregnant? *

given birth? *

How was your experience of birthing your own children? *

How old are your children now? or if pregnant, how many weeks at time of workshop? *

Have you ever experienced a miscarriage? *

Yes No

abortion? *

Yes No

stillbirth? *

Yes No

Notes (anything you would like to share) *

Do you have any serious medical condition that may be affected by movement, breathwork or excitement? *

Yes No

Details: *

Are you taking any medications? Or have you done so in the weeks prior to attending? *

Yes No

Details: *

Please provide details of next of kin in unlikely case of emergency: *

First

Last

Contact Number *

Relationship to you *

Do you have any special dietary requirements / allergie s with severe reactions? *

Yes No

Details: *

Anything else you would like to share with us? *

We are very much looking forward to connecting with you soon. Thank you for joining us and please do be in touch if you have any further questions.

Birthintobeing.aust@gmail.com
Nicole – 0447353297

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Education
Midwives
Doulas
Yoga
Support
Comp Therapy
Fertility

8 Porter St
Briar Hill
Victoria, 3088
0409 955 779

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www.mojain.com.au