Client Info and Contraindications Form

Client Information

Name

Email *

Phone

DOB

Doctor Surgery Name

Are you on any medication?

Level of stress out of 10

Are you in Menopause? *

Are you in Perimenopause? *

Are you actively suffering with Post Traumatic Stress Disorder? *

Do you know any other reason why you should not do physical activity?

To get the most out of our sessions, it is useful to know:

What brought you here?

What’s your presenting issue?

Are there any big changes going on in your life?

Are there any major events in your past that you think might be worth naming?

Are all of the below listed relationships stable or are you struggling with any of them at the moment?

Do you have any history of trauma?

How is your sleep?

How is your diet?

How is your weight?

How is your substance intake e.g. smoking, alcohol, drugs etc. ?

What is your current level of fitness?

What is your current fitness routine?

Do you have any pain?

Do you have any inflammation or tiredness?

Contraindications:

Tension & Trauma Releasing Exercises by David Berceli, can treat many illnesses, but you need to let me know whether you have any of the below contraindications:Physical limitations, Irregular blood pressure (high or low), Irregular heart conditions (surgery, pacemakers, arrhythmia),Physical limitations (broken bones, strains, sprains, chronic aches), Operations, Hypo or hyperglycemia (medications), Pregnancy, Epilepsy, Psychiatric conditions (with medication); Manic/depressive, Bi-polar conditions, Schizophrenia, Severe depression, Psychosis, Borderline personality disorder

Declaration

Consent *

I do not suffer from any medical conditions listed on this form.
I will seek medical approval from my GP should the situation with my health change.

Consent *

Yes, I agree with the privacy policy and terms and conditions.