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            CLIENT HISTORY / PERSONAL INFORMATION
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Answer each question as truthfully as you can.  You need not be concerned
about accuracy.

1) What do you believe about your own personal birht (not your child's)?


2) What does your mother believe about your birth?


3) What does your father believe about your birth?


4) What does your mother believe about women?


5) What does your father believe about women?


6) How would a group of women from your family (aunts, sister, grandmothers,
   etc.) fill in this statement?

   The women in our family are...


7) How would a group of women from your family (aunts, sister, grandmothers,
   etc.) fill in this statement?

   Childbirth is...


8) What did you believe about sex at the age of 16?


9) What does your mother believe about sex?


10) What does your father believe about sex?


11) What do you believe about pregnancy?


12) What does your mother believe about pregnancy?


13) What does your father believe about pregnancy?


14) How do you feel about talking to a physician?


15) What have your friends told you about pregnancy?


16) What have your friends told you about childbirth?


17) What three words to you associate with pain?

   a)
   b)
   c)

18) What three words to you associate with a hospital?

   a)
   b)
   c)

19) What are your three most secret thoughts about childbirth?


21) What do you fear the most about your birth?



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                     SOCIAL HISTORY FORM
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Name:

Marital Status:   Single  Married  Separated  Living Together  Widowed

   How Long?

Years of Education:                Highest Degree Attained:

Religious Preference:


Occupation:

Place of Birth:

Names of other persons living in your home:


What are your spiratual beliefs and how do they affect your life?


What type of physical activity are you doing?


How much exercise do you get per week?


What do you think makes people healthy, and what makes them sick?


What are your special interests?


List the places you have received health care in the last five years:


Please describe your current emotional status (How are you feeling?):


Who do you turn to for support?


How was your relationship with your parents when you were growing up?


Have you ever had psychotherapy and/or taken psychotherapeutic drugs?  If so
what kind?


Are you involved in personal growth activities?


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Women's Health & Birth Care
1826 Portsmouth
Houston, Tx 77098

FAX: (713) 529-9494

This form is available at:
http://www.houstonnaturalbirth.com/forms/client_history.txt