General Information Form for TRE® Session

with Janine Saxe, Rest and Motion, LLC

First name

Last name

Phone

• This is not an intake or medical form. It is an information form so that you and your Certified TRE® Provider can discuss any issues or concerns that might be important to you prio to participating in the exercises.

• It is generally agreed that if you are healthy enough to go to the gym, then you are healthy enough to do TRE®

• We recommend that you consult with your medical doctor prior to beginning any physical activity or exercise program.

• Always work within your physical limits. If any of the exercises cause any discomfort please let me know and we will find an alternative.

If you answer YES to the following questions please explain,

otherwise please type NO.

Have you had any surgeries, hospitalizations, accidents or injuries that may prevent you from doing any type of physical movement or exercise?

Are you receiving any type of medical treatment that would prevent you from doing any type of physical exercise?

Do you participate in regular physical activity? - Describe briefly (type and frequency)

Do you have any limitations to movements or activities?

Are you taking any medications/herbs that may cause dizziness or balance problems?

Please bring to my attention any of the following conditions that currently affect you.

There is no know contraindications to TRE®. However, the following is a list of cautions or conditions we need to be mindful of as you go throug the TRE® process. If you have any of the following conditions, you should let your Certified TRE® Provider know and work within your comofrt zone. Go slowly and be gentle with yourself. Stop if you have any concerns, feelings of discomfort or stress.

If you have experienced prolonged or severe trauma in your lifetime it is often best for you to learn TRE® from a mental health professional (i.e. a psychotherapist who has trained as a TRE® provider). If this describes your situation please reach out to me so we can discuss the best course of action for you.

Indicate any of the following conditions you currently have:

Irregular blood pressure (high or low)

Irregular heart conditions (surgery, pacemaker, arrhythmia)

Physical limitations (broken bones, sprains, chronic aches)

Recent surgeries

Hypo or Hyperglycemia

Epilepsy

Pregnancy (Should only do TRE® with a Certified TRE® Provider who has expertise in this area)

If you have any of the following conditions that are being treated with medications please indicate.

Manic/depressive

Bipolar conditions

Schizophrenia

Severe Depression

Psychosis

Borderline Personality Disorder

If there are any other health concerns not listed above that you feel are important for me to know prior to performing the exercises please describe:

Health Concerns - Please list any current health concerns in order from most bothersome to least bothersome. Include any mental, emotional or physical concerns.

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