Questionnaire - Treatment Centre - Myofascial Energetic Release

Questionnaire prior to your visit to the MER Treatment Center in Greece

In order to offer you the highest level of therapeutic support during your treatment in our center, we need to know you better. Please, respond as precisely as you can to the following questions. Your responses will be used carefully only by the facilitators of the center who will offer you individual sessions.

Personal data

First Name

Last Name

Telephone

Country

Age

You Motivation In Coming To Our Center

What is the purpose of your visit at the center?

Have you ever experienced any other kind of bodywork or movement modality?

Have these treatments been effective or ineffective or just given you temporary relief?

What is your expectation of working together?

Some Questions About The Issue Or Pain You are Experiencing

When did your pain/issue start showing up?

What do you remember about this moment?

Is the emergence of this pain related to a stressful moment in your life?

Is the appearance and severity of the pain consistent in time?

How is the pain influencing your life?

Are you thinking about the pain often?

Can you describe the sensation in your body when the pain appears?

More Information About Your Global Health

Are you taking any medication right now and which one (if he/she wants to disclose)?

Have you undergone surgery within the last 6 months? YesNo

Have you undergone drastic surgery in your life (and is it still affecting you now)?

What is your sleeping quality like?

How would you describe your eating/drinking pattern?

How is your body awareness?

Terms and Confidentiality AgreementPlease read our Terms and Confidentiality Agreement.

I agree that my personal information may be used and stored by Satyarthi Peloquin and its team members for the purpose of responding to my request.