Block Therapy Fascia Alignment Assessment Form

Fascia Alignment Coach 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 your Block Therapy Instructor & Fascia Alignment Coach Jennifer Kroeker and Deanna Hansen.
Your Name
Date
Phone Number
Please enter a valid phone number.
Email
example@example.com
YesNo
Date of Birth:

MonthDayYear
Date
Time Zone
What is your dominant side?
What are your three main areas of concern/focus
PregnancyImplantsPacemakerSurgical MeshSurgery or ScarsSpinal Rods or Metal PinsBroken BonesAdvanced OsteoporosisOther
Please list any current medical conditions you are dealing with
How much time per day can you commit?
Block Therapy 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. Please email them to your Block Therapist @ fitnesswithjen2@gmail.com
Please send 4 photos: 1. front, 2. back, 3. left side 4. 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 your hair in a ponytail.
- Make sure the camera is straight on, not on an angle.
- Use a well-lit indoor space. Use a plain background - a blank wall or door P.S. 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 your photos.

My Products

Assessment

Includes consult, assessment and program. An assessment of your body is completed, you are prescribed a block program for 4 weeks and follow the videos prescribed in a block therapy membership. Block Therapy Membership cost not included in Assessment fees.

$100.00CAD

Total

$0.00CAD

Credit Card

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