Name
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First Name
Last Name
Email
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Phone
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(###)
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Date of birth
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MM
DD
YYYY
Sex assigned at birth
Gender identity
Pronouns
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Emergency contact (name and phone number)
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Why are you seeking bodywork at this time?
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Please check the modalities you are interested in receiving (a session with me can be a combination of modalities, so choose those you are interested in and we can discuss a plan for your session)
Please describe your current health concerns in detail. Include specific information such as when the symptoms started and any treatments you are currently undergoing.
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Is there a possibility that you could be pregnant?
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List all medications, supplements, and/or herbal remedies that you are currently taking
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Provide information about any allergies or sensitivities you have, specifying the triggers and the reactions experienced
Describe any regular or daily activities that you find difficult or have limitations with
List your daily activities that engage your body in repetitive movements or periods of holding it in specific positions
Describe the activities or practices you engage in for relaxation, as well as the frequency with which you typically engage in them
Describe the quality and length of your sleep
Take a moment to scan your body and indicate any areas where you experience pain, tension, discomfort, or a sense of blockage. You can check the corresponding boxes for each area that applies to you:
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Provide more details about the specific body parts you checked above. For each area, describe what you are feeling (e.g., pain, tension, numbness), the intensity of the sensation on a scale of 1 to 10 (with 1 being mild and 10 being severe), and any additional information you would like to share about those areas.
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Provide information about any surgeries, injuries, or accidents you have experienced in the past, including the year in which they occurred
Feel free to use this space to provide any additional information or details that you think would be important for me to know. You can share specific preferences or any other relevant information that you believe would be helpful for me to address your needs effectively.
Consent
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Bodywork sessions are performed by Tatiana Godoy Betancur (Oregon LMT no. 27601). The modalities offered are not meant to diagnose conditions or substitute medical treatment. For diagnosis or treatment of any medical condition, please consult your physician.
Where hands-on touch is appropriate in a session, it is non-sexual, safe, and within your consent and boundaries.
All information shared during sessions, including the information provided in this form, will be kept confidential and will not be disclosed without your written consent.
To create a comfortable environment for all clients, please refrain from wearing any synthetic fragrances, including perfumes, colognes, or scented lotions, to your session. Your cooperation is appreciated.
By typing your full name and the date below you confirm that you have read and understood the above.
