Birth Time Rectification Questionaire

                    Name:______________________________  Sex:___

Known Birth Data

                    Date of birth:______________________   Source:_____________
                    Time of birth:______________________  AM / PM
                    Place of birth:___________________________________________
                            (if rural, give name of nearest town & mileage & direction from)

  • Please provide the most accurate information you can. If exact date is not know, please indicate an approximate time span, i.e. within 1 week, within 2 weeks, etc. Include times wherever possible, i.e. scheduled surgeries or accidents. The better your information is, the more accurate the rectification can be.

     
  • 1.    Date of mariage(s)  
  • 2.    Date of divorce(s)  

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  • 3.    Birth of children, dates and sex
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  • 4.    Unusual conditions surrounding deliveries (forceps used, caesarian, etc. anything unusual identify which child
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  • 5.    Date of birth of spouse(s)
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  • 6.    Date of death of spouse(s)
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  • 7.    Dates of death of mother/father
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  • 8.    Dates of death of children (include miscarriages and stillbirths)
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  • 9.    Dates of deaths of others extremely important to you (grandparents, stepparents, others i.e. "she was as close as a mother") and the relationship
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  • 10.    Serious accidents, please describe accident and provide date(s)
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  • 11.    Major surgeries, describe type and date(s)
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  • 12.    Major illnesses, describe and date(s)
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  • 13.    Any chronic health condition (high blood pressure, diabetes, anemia, etc...)
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  • 14.    Any physical disability that is not a result of any of the major illnesses, surgery or accidents descibed above. (birth defects, etc.) 
  • 15.    Occupation(s) 
  • 16.    Dates of changes in occupation or job position (i.e. promotions/transfers)
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  • 17.    Loss of job(s), reason(s) and date(s)
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  • 18.    Date of graduation from high school
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  • 19.    Date(s) entered and date(s) of graduation from college/grad school
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  • 20.    Dates of service in armed forces, include date inducted and discharded. Include branch of service

    21.    Do you smoke?  Yes/No    How much?

  • 22.    Do you drink alcohol?  Yes/No     How much?  
  • 23.    Are you considered an alcoholic?  
  • 24.    Is there any other substance abuse/use? If yes, please describe.
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  • 25.    Have you ever been in jail, please include date(s)
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  • 26.    Major travel, ocean voyages, etc. and dates of travel
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  • 27.    Inheritances, from whom? Include date
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  • 28.    Have you ever won a lottery? Include date(s)
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  • 29.    Election to office (public, social club, etc.) and date(s) of election
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  • 30.    Any other conditions or events you consider unusual, different or important? (intelligence, habits, aptitudes, etc.)  
  • 31.    Date(s) of major turning point in life, describe (may include above events)
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  • 32.    Height __________  Weight __________   Birthmarks or scars ___________________________________

  • 31. Please enclose if possible 1 snapshot of you - full lenght (full body) and 1 close-up (head). Thank you.
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  • All information confidential. Accuracy of the rectification depends upon the accuracy of the information given.  

     

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