Cosmic Mapping Questionnaire Name * First Name Last Name Email * Date MM DD YYYY Do you know your birth story? If so, briefly share it below. Do you know your mother's mental and physical well-being during her pregnancy. If so, briefly share below. If you are a woman at what age did you begin menstruation? At what age did you begin exploring your sexuality? * *Sex is not limited to penetration 0-7 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? * *only list what stands out in your memory 7-14 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? * *only list what stands out in your memory 14-21 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? * *only list what stands out in your memory 21-28 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? * * only list what stands out in your memory 28- 35 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? *only list what stands out in your memory 35-42 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? *only list what stands out in your memory 42-56 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? *only list what stands out in your memory 56-63 years: What diagnosis, injuries, traumatic events/relationships occured during this time of your life? *only list what stands out in your memory Share a few key words that would describe your mother and grandmother. *leave blank if you never knew either one. Thank you! Information shared here is confidential and will not be shared with anyone or saved beyond our time together.