test-formulär - Tension Releasing Exercises

Firstname *

Date of Birth *

Surname *

Age *

Gender *

Mobile phone number *

City *

E-mail *

Occupation *

Country *

Next of kin/ Emergency contact - Name *

Next of kin / Emergency contact - Phone # *

Relationship next of kin / Emergency contact *

Have you done TRE® before? *

If yes, please describe your experience of TRE® - how long you’ve been practicing, where and when you learned, how often you shake and any significant changes that have occurred.

What are you hoping will be different as a result of doing TRE®?

Do you currently have any medical conditions? *

Please provide details of any heart conditions, irregular blood pressure, epilepsy, diabetes or ongoing chronic pain.

Is your movement or physical ability restricted in any way? *

Please include details of any problems with your ankles, knees, hips, spine or neck

Do you experience any sensory impairment (such as vision or hearing loss or balance issues)? *

If yes, please explain any sensory impairment

Are you currently receiving (or have you received) any psychiatric care, therapy or counselling for anxiety, depression or any other mental health challenges? *

Please provide details of any treatment you've received within the last 12 months

What medications (prescription or over-the-counter), vitamins, supplements or natural remedies do you take regularly?

Have you experienced any trauma within the last 24 months? If yes, please describe. *

Are you pregnant?

For women only

If yes, how many weeks?

Headaches or migraines? *

Hardly ever
Monthly
Weekly
Daily

Back, neck, shoulder pain? *

Hardly ever
Monthly
Weekly
Daily

Pelvic pain? *

Hardly ever
Monthly
Weekly
Daily

Knee pain? *

Hardly ever
Monthly
Weekly
Daily

Fibromyalgia? *

Hardly ever
Monthly
Weekly
Daily

Allergies? *

Hardly ever
Monthly
Weekly
Daily

Digestive issues? *

Hardly ever
Monthly
Weekly
Daily

Nausea? *

Hardly ever
Monthly
Weekly
Daily

Worry? *

Hardly ever
Monthly
Weekly
Daily

Anger/rage? *

Hardly ever
Monthly
Weekly
Daily

Sadness? *

Hardly ever
Monthly
Weekly
Daily

Lack of energy? *

Hardly ever
Monthly
Weekly
Daily

Insomnia? *

Hardly ever
Monthly
Weekly
Daily

Irritability? *

Hardly ever
Monthly
Weekly
Daily

Depression? *

Hardly ever
Monthly
Weekly
Daily

Anxiety? *

Hardly ever
Monthly
Weekly
Daily

Panic attacks? *

Hardly ever
Monthly
Weekly
Daily

If you have any of the following conditions, please select yes or no.

Irregular blood pressure (high or low) ? *

Hypo or Hyperglycaemic (medications)? *

Recent surgeries ? *

Irregular heart conditions (including surgery, pacemakers, and arrhythmia) ? *

Vertigo/dizziness, particularly when bending over? *

Psychological conditions (such as PTSD)? *

Chronic pain (Fibromyalgia / MS)? *

Chronic fatigue (ME)? *

Other (please describe below)

IMPORTANT: If you have any of the following conditions we advise that you only work with Certified TRE® Providers whose scope of practice includes experience in the treatment of these conditions. (If you have a therapist or friend you may bring them with you to learn TRE® too or support you with your TRE® in your one-to-one session.) And do not do your first few sessions of TRE® in a group.

Manic/depressive? *

Bipolar conditions? *

Schizophrenia? *

Severe depression? *

Psychosis? *

Borderline Personality Disorder? *

On a scale of one to ten, with ten being the most intensive, how would you evaluate the following on an average day?

Physical pain levels? *

Emotional pain levels? *

Current stress levels? *

Do you have any other concerns you would like to share before attending a TRE® session?

Do you have any questions about TRE® prior to our scheduled session?

Write your signature *

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