Pre-Participation Health Questionnaire

A short, required pre-participation form · Takes about 5 minutes

A gentle note

Answering Yes to any question does not necessarily prevent you from taking part. The information helps determine whether any modifications, further discussion, or medical clearance may be appropriate.

Your Details

So we can stay in touch and personalise your experience.

Full Name *

Please enter your name.

Date of Birth *

Please provide your date of birth.

Email *

Please enter a valid email address.

Phone Number *

Please enter your phone number.

Physical Health

A few questions about your body so we can hold the space safely for you.

1.Have you had surgery within the past six months? *

Yes

Please select an answer.

If yes, please provide details:

2.Do you currently have any injuries or medical conditions that may affect your ability to participate in gentle physical exercise? *

Yes

Please select an answer.

If yes, please provide details:

3.Have you ever been diagnosed with any of the following: heart disease, high blood pressure, epilepsy/seizures, osteoporosis, or significant spinal problems? *

Yes

Please select an answer.

If yes, please describe the condition, whether it is well controlled, and whether you have any activity restrictions advised by your healthcare professional:

4.Are you currently pregnant? *

Yes

Please select an answer.

If yes, how many weeks?

Mental & Emotional Health

These questions help me hold a safe, attuned space for your nervous system.

5.Are you currently receiving treatment from a GP, psychiatrist, psychologist, psychotherapist or mental health team? *

Yes

Please select an answer.

If yes, please provide brief details:

6.Have you experienced psychosis, a manic episode, or psychiatric hospital admission within the past 12 months? *

Yes

Please select an answer.

7.Have you experienced significant trauma that still feels very distressing or overwhelming? *

Yes

Please select an answer.

8.Do you experience episodes where you feel detached from yourself or your surroundings (dissociation)? *

Yes

Please select an answer.

9.Are you currently experiencing thoughts of harming yourself or feeling that life is not worth living? *

Yes

Please select an answer.

If you answered Yes, please reach out for support:

Samaritans: 116 123 (free, 24/7)
NHS 111 — for urgent mental health support
Your GP or mental health team — please let them know

Anything Else?

Optional space for anything you'd like me to know.

10. Is there anything else about your physical or mental health that you feel I should know before you participate?

Declaration

Please read and confirm to continue.

I confirm that the information I have provided is accurate to the best of my knowledge.

I understand that TRE involves gentle physical exercises followed by natural muscular tremoring. I may stop at any time if I feel uncomfortable.

I understand that TRE is intended as a wellbeing practice and is not a substitute for medical or psychiatric treatment.

Participant Signature (type your full name) *

Please type your full name to sign.

Date *

Please provide the date.

Pre-Participation Health Questionnaire

Your Details

Physical Health

Mental & Emotional Health

Anything Else?

Declaration

Thank you

A space held with care