Personal Assessment Form

Therapist Assessment Form & Photo Submission

The following form is designed to provide you with optimal support and guidance in addressing any issues you identify as being of concern to you and any medical conditions or devices that need to be considered when creating programs specific to your needs. It greatly assists in designing the best program(s) for you to experience maximum results.

Always consult your physician before beginning this or any bodywork or exercise

Note: All information and photos are confidential to me, Sabrina Fritts, as your Block Therapist and Deanna Hansen, founder of Block Therapy.
Your Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Time Zone
What is your dominate side?

I am Right HandedI am Left HandedI am Ambidextrous
What are your three main areas of concern/focus?
Please indicate whether the following apply to you:

PregnancyImpantsPacemakerSurgical MeshSurgery/ScarsBroken BonesSpinal Rods/Metal PinsAdvanced OsteporosisOther
Please list any current medical conditions you are dealing with
Photo Requirements

Your Block Therapist will need to see 4 photos of you to be able to identify your unique fascia holding patterns in your body, and be able to suggest the best protocol. Below are our suggestions for taking the photos:
- Send front, back, left side and right side photos.
- Stand naturally with your arms by your side.
- Include your full body, from head to toe.
- Show as much skin as you feel comfortable (Sports bra and shorts, bathing suit, etc).
- Put long hair in a ponytail.
- Make sure the camera is straight on, not at an angle.
- Use a well-lit indoor space.
- Use a plain background - a blank wall or door.
- Selfies don't count ~ ask someone in your household for assistance or use a tripod!
Below is an example that shows the above requirements for taking your photos.
Upload Photos

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