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Body Ready Method
New Client Questionnaire

Thank you for taking the time to complete this questionnaire. It helps me to support you better!

"*" indicates required fields

All information received on this form will be treated as strictly confidential. Please fill out the forms completely and accurately. This information is essential to developing a program that addresses your needs, goals, and interests and is safe and effective.

Name*

First Last

Today's Date*

Month

Day

Year

Phone*

Email*

Enter Email Confirm Email

Date of Birth*

Month

Day

Year

Occupation*

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Name*

Name

Emergency Contact Phone Number*

MEDICAL HISTORY

Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?*

Yes

Do you frequently have pains in your chest when you perform physical activity?*

Yes

Have you had chest pain when you were not doing physical activity?*

Yes

Do you lose your balance due to dizziness or do you ever lose consciousness?*

Yes

Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc/)?*

Yes

Are you pregnant now or have given birth within the last 6 months?*

Yes

Have you had a recent surgery?*

Yes

Please explain any YES answers from above*

Please list any sports or physical activities that you have participated in regularly in the past and in what capacity you participated.

Please check all conditions you have encountered throughout your lifetime:

HEAD/NECK

TMJ/Teeth grinding

Jaw pain

Headaches

Neck pain

Hearing/Vision loss

Sinus infections/allergies

Thyroid dysfunction

Other head/neck issue

NEUROLOGICAL/LIMBIC

Alzheimer’s

Memory loss

Brain fog

Anxiety/panic attacks

Depression

Other

RIGHT SHOULDER

Rotator cuff injury/pain

Shoulder impingement

Shoulder injury/pain

Other shoulder issue

LEFT SHOULDER

Rotator cuff injury/pain

Shoulder impingement

Shoulder injury/pain

Other shoulder issue

SPINE/UPPERBACK

Upper back pain/injury

Osteopenia/osteoporosis

Other

SPINE/LOWER BACK

Lower back pain/injury

Osteopenia/osteoporosis

Other

LYMPHATIC

Lymphoma

Lymph node swelling

Breast cancer

Fatigue

Other

CARDIOVASCULAR

High blood pressure

High cholesterol

Stroke

Heart disease

Other

RESPIRATORY

Asthma

COPD

Shortness of breath

Lung disease

Other

DIGESTIVE

Constipation/diarrhea

Acid reflux/heartburn

Diverticulitis

Gallstones

Unexplained weight gain or loss

Other

ORGAN FUNCTIONS

Diabetes

Kidney disease

Appendicitis

Liver dysfunction

Adrenal dysfunction

Other

REPRODUCTIVE/UROLOGIC

Menstrual cramps/pms

Yeast/bladder infections

Infertility/miscarriage

Urinary incontinence

Kidney stones

Other

RIGHT ARM/HAND

Carpal Tunnel

Tennis elbow

Numbness in hand

Hand always cold

Osteopenia/osteoporosis

Other

LEFT ARM/HAND

Carpal Tunnel

Tennis elbow

Numbness in hand

Hand always cold

Osteopenia/osteoporosis

Other

RIGHT LEG/KNEE

ACL Injury

Cartilage concerns

Knee pain/injury

Leg pain/injury

Edema (swelling)

Knee replacement

Other

LEFT LEG/KNEE

ACL Injury

Cartilage concerns

Knee pain/injury

Leg pain/injury

Edema (swelling)

Knee replacement

Other

RIGHT FOOT/ANKLE

Bunion

Hammertoe

Plantar fasciitis

Numbness in foot

Foot always cold

Foot pain/injury

Ankle pain/injury

Edema (swelling)

Other

LEFT FOOT/ANKLE

Bunion

Hammertoe

Plantar fasciitis

Numbness in foot

Foot always cold

Foot pain/injury

Ankle pain/injury

Edema (swelling)

Other

Please further describe any boxes you checked above that you feel need further explanation.

Please list and briefly describe any previous injuries and hospitalizations/surgeries.*

What are your goals for our session(s)?*

Please describe for me what led you to set up your appointment with me for BRM?*

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"She made me believe that I did everything I could. That I was strong. That mattered to me. I am thankful to the moon and back that I had her there."

- Ivory

"Adrianne was so amazing and helpful to not only me, but my partner Shaun! I truly don’t think my birth would have went as smoothly as it did without her! She is so gentle, kind, attentive, and caring. I felt so safe and supported by her."

- Grace

"Adrianne provided immediate comfort to Lei when her water broke unexpectedly a month in advance. She stayed with us for most of the labor and delivery, offering advocacy, support, encouragement, wisdom, expertise. She was a constant reassuring presence, greatly reducing the stress of one of life's most stressful occasions. She met with us beforehand and afterwards and shared her experience and advice with warmth and compassion. Highly recommend!"

- Lei & Sean

"Adrianne was an essential part of my labor and delivery. Her compassion and gentle approach helped me tremendously. She reminded me and assisted me with moving my body when it was the last thing I wanted to do. Through every scare and worry, I could rely on Adrianne to be there for me. When I experienced a postpartum hemorrhage, she made sure not to leave my side and went above and beyond with her care!"

- Chloe

"Adrianne was a delight to work with for the birth of our son. I truly believe our experience would have been completely different if she hadn't been there to guide and support us throughout the weeks prior to delivery and during labor itself. Adrianne made herself available to me whenever I needed and even came over on several occasions to help me through prodromal labor and guide me to engage baby. I wish I would have had her for our first!"

- Madison

"Adrianne did a fantastic job of guiding my husband and giving him tools so that he could be the most supportive partner possible. He was grateful that we decided to hire her. I would highly recommend Adrianne...!"

- Marian

"(Adrianne) was the MOST help out of everyone on my team and I can not be more grateful for her. She was so respectful, and I loved the energy she always brought to every challenge that I faced."

- Clarissa

"Adrianne was an incredible listener, really caring to answer my questions/concerns thoroughly. She is very sincere and genuine in her concern for her client. Adrianne was absolutely wonderful in so many ways before, during, and after the birth. She truly went above and beyond, and I could not be more grateful to have worked with her."

- Amy

"Adrianne was very informative with all things pregnancy, delivery and baby related...My husband and I were so grateful to have her there to help guide us through positions to adjust the baby as I was having horrible back pain. She brought a calming and confident feeling to the intense moments I was experiencing while in labor. She gave the perfect balance of offering a hand, being there to help advocate for my choices while also allowing my husband and I to work seamlessly together..."

- Kimberly

"...When first meeting Adrianne, we talked and talked and I could tell her calming presence and confidence would be a great counterbalance to my uncertainty and my anxious feelings. Throughout all of our prenatal meetings, she was encouraging and you could tell she valued meeting me where I was at, and gauging what was important to me so she could honor my wishes. Our discussions made me really think through my feelings and thoughts in ways I hadn't considered before, which in turn helped me prepare for the process..."

- Ani

"Adrianne was such a positive part of our pregnancy and the birth of our daughter! My husband and I are both physical therapists, and we appreciated Adrianne's knowledge on how movements, positions, and breath work could help us to achieve our natural birth goals. During labor and delivery, she was a calm presence and helped us to stay focused on the beauty and power of the time, giving us a sense of control during our birth experience. The prenatal education and postpartum support she provided were invaluable. We would (and have!) highly recommend working with Adrianne as your birth doula!"

- Alaina

"I wouldn't have been able to get through my natural labor without Adrianne! From the moment I met her I just knew that her calm and comforting spirt would bring me so much ease. She had taken so much time to make sure I was taken care of both physically and mentally for my baby's birth day!"

- Mahayla

Contact Me for a Free Consultation

Let's Chat

I feel passionate about helping others find their courage, strength, and instinct to trust their bodies and step into their power to have the birth experience they want. It is an honor to walk alongside you, hold space for you and allow the physiological process of birth to unfold.

Serving the Greater Tacoma, WA area including Puyallup ~ Sumner ~ Bonney Lake ~ Federal Way ~ Auburn ~ Gig Harbor ~ JBLM ~ Olympia ~ Lacey

~And other surrounding South Sound cities~

(253) 254-5142
adriannebuyer@gmail.com

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Body Ready MethodNew Client Questionnaire

Thank you for taking the time to complete this questionnaire. It helps me to support you better!

MEDICAL HISTORY

Please check all conditions you have encountered throughout your lifetime:

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Contact Me for a Free Consultation

Body Ready Method
New Client Questionnaire