To use this Form all you need to do is copy it to your word processor or email program. {If you have trouble highlighting the text and are using netscape, switch to microsoft to make the copy}.

Type your information in and email it back to me at:
subject: Sharing our Wisdom.

Your participation will help my research and I thank you in advance for filling out the form to the best of your ability.


Do you wish to share your experience with others on the web?
How do you want to be identified? By first name only? or by Pen name? which would be.....

email address:
In case I have any questions or something needs clarification. Your email address will NOT be posted publicly. I have the utmost respect for your privacy.

Would you like to support other women as they go through this experience?
If yes, please join my herbal abortion support group, you can help other women by being available to talk about your experience. Messages can also be viewed online if you prefer not to have things delivered to you email box.
Herbal Abortion Support

If you are a herbalist/midwife/doula or other professional who is willing to guide women through herbal abortion, or can do menstrual extractions, please send your contact information, which will be kept private, but given by me to those in your area requesting help.

Not all information you provide will be posted publicly. Some of the questions are for my information only and assist me in my research.

Ethnic Background:

What state, country do you currently live?

Did you have a pregnancy test?
When was it taken?
What was the result.
If more than one test was taken please include info for each one.

If no pregnancy test was taken - do you think you were pregnant?
How strongly do you feel this way?

How was the pregnancy ended?

Were you successful in using the herbs?
Would you try herbs again, or recommend them to a friend in the same situation?

Is this your first pregnancy?
Do you have children?
Have you had any previous natural miscarriages?
Is there a history of natural miscarriages in your family?
Any previoius herbally induced miscarriages?

What was the date of the first day of your last menstrual period?
If you know the date fertilization occurred, what was it?
What was the date you were expecting menstruation?

The "average" monthly cycle is 28 days, how long are Your average cycles?
Do you cycle regularly or irregularly?

What was the date when the herbs were started?
How many weeks pregnant were you when the herbs were started?
For how many days were the herbs used (total)?

What was the date the pregnancy was terminated?
Or.... what was the date bleeding started if herbs were successful?

Is there anything that indicated that the herbs might be working before bleeding started?

Were you using birth control?
What kind/method of birth control/contraception were you using?
Do you know how/why it failed?
If you were not using birth control, please share why not.

Did you experience any symptoms or signs of pregnancy?
When did they start?

Info on herbs you chose to work with:
Name of Herb(s):
Form Taken:
Amount taken:
Side effects.

How did the herbs affect you?
Any positive effects?
Where there any negative effects?
Do you smoke tobacco?
Do you have any health problems or issues?
If yes, do you think it had any affect on the way the herbs affected you?
How did the herbs make you feel physically?
How did being pregnant make you feel physically?

Have you been under any unusual stress this month? especially during the time following your last period? Illness? Travel?

Did you or your partner desire this pregnancy on some level?
How clear were you about ending the pregnancy when it was discovered?

If the herbs caused miscarriage -- how did you feel just before bleeding began?
When bleeding started - How was the bleeding, cramping, etc?

If the herbs didn't cause miscarriage -
Do you have any thoughts on why it might not of worked?
Anything you would of done differently?

Could you reflect on the process of a herbal abortion and write a paragraph about it. I would like to add something of this nature to my website, but would like other experiences to draw upon besides my own. Thanks.

What steps do you plan to take to help to protect yourself better?
Do you feel can you use this experience to learn and grow?
Do you feel like you are in a supportive environment?

Have you allowed yourself to feel and process your emotions surrounding this event?

Thank you for filling out my questionnaire. The information you have provided will assist me in my research. Thank you.

Your Story - Please type it as you want it to appear. I don't edit this part, so it will be as you post it. If you would not like to have your comments posted publicly that is ok, just make note above in the questionnaire. I am always collecting information about this subject and any info is greatly appreciated. Many women who have found themselves faced with unwanted pregnancies have expressed their appreciation and gratitude to all those who came before and agreed to have their experiences posted here. Many women have found comfort and courage from the Sharing our Wisdom section, maybe you are one of them. This is your opportunity to share your experience with other women, so tell it as you will.
Thanks for contributing to our body of knowledge!!

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