Block Therapy Questionnaire
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
Name
First Name
Last Name
Your Gender
Please Select
Female
Male
Other
Your Age
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
What is your job?
Preferred Blocking Schedule: (select all that apply)
Mornings
Mid-Day
Afternoons
Evenings
Weekdays
Weekends
How many days a week would you like to Block with Jen?
1
2
3
4
5+
4. How much time can you commit to each Block session?
60 Minutes
90 Minutes
Would you prefer: (select all that apply)
In-Person at Jen's gym
Online
Do you have any of the following? (select all that apply)
Pregnancy
Implants
Pacemaker
Surgical Mesh
Surgery or Scars
Spinal Rods or Metal Pins
Broken Bones
Advanced Osteoporosis
What is your dominant side?
Please Select
Right Handed
Left Handed
Ambidextrous
Please list any current medical conditions you are dealing with:
What are your three main areas of concern/focus?
Any additional comments/concerns you may have?
Submit
Should be Empty: