ALIGN Mat- Self-Reported Case Submission Form

Self-Reported Case Submission Form
Instructions for Completing This Form

This form is intended for individuals to document their experience with ALIGN Mat. You will be able to describe the specific protocol you followed and report any changes or outcomes you observed.

Please complete all sections of the form, providing accurate and honest responses that reflect your condition before and after the full treatment period you are reporting on. Treatment durations may vary, and this form is designed to accommodate different personal protocols.

Your input is valuable and may contribute to a better understanding of individual responses to ALIGN Mat, especially in real-world, at-home use settings.
Section 1: Personal Info
(Your responses will be reported anonymously)
Name*

First NameLast Name
Email*
example@example.com
State, Country*
Date of Birth*

MonthDayYear
Date
Gender*
Relevant Medical History*
Short Description of Your Main Concern or Reason for Using ALIGN Mat: What issue or goal led you to begin using the products?*
Duration of symptoms*

Acute (<1 month)Subacute (1-3 months)Chronic (>3 months)Other
Section 2: Clinical Baseline Assessment

Section A – BEFORE ALIGN Mat

Select a score from 0 to 5 based on your assessment, where 0 indicates the worst possible status and 5 indicates the best.
Overall Wellness: How would you rate your general sense of wellness?*

0

1

2

3

4

5

0 is Very poor overall wellness, 5 is Excellent overall wellness
Energy Levels: How would you rate your overall energy throughout the day?*

0

1

2

3

4

5

0 is No energy at all, 5 is Full of energy
Mental Clarity: How would you rate your ability to think clearly and stay focused?*

0

1

2

3

4

5

0 is Constant brain fog, 5 is Extremely clear and focused
Physical Recovery: How would you rate your ability to recover from physical exertion or fatigue?*

0

1

2

3

4

5

0 is Very slow or no recovery, 5 is Rapid and complete recovery
Stress Resilience: How would you rate your ability to handle stress effectively?*

0

1

2

3

4

5

0 is Overwhelmed by stress, 5 is Calm and resilient under stress
Mood Stability: How would you rate your overall mood and emotional balance?*

0

1

2

3

4

5

0 is Very unstable or low mood, 5 is Consistently positive and balanced mood
Sleep Quality: How would you rate the quality of your sleep?*

0

1

2

3

4

5

0 is Very poor sleep, 5 is Excellent, restful sleep
Motivation: How would you rate your motivation to complete daily tasks and goals?*

0

1

2

3

4

5

0 is No motivation, 5 is Highly motivated and driven
Anxiety Levels: How would you rate your overall level of anxiety in daily life?*

0

1

2

3

4

5

0 is Extremely anxious or constantly on edge, 5 is Completely calm and free of anxiety
Physical Performance: How would you rate your physical performance or stamina?*

0

1

2

3

4

5

0 is Very poor physical performance, 5 is Excellent physical performance
Mental Recovery: How would you rate your recovery from mental fatigue or overexertion?*

0

1

2

3

4

5

0 is Prolongued mental exhaustion, 5 is Quick and complete mental recovery
Physical Comfort: How would you rate your overall physical comfort in daily life?*

0

1

2

3

4

5

0 is Frequent discomfort of pain, 5 is Completely comfortable and free of physical discomfort
Section 3: ALIGN Mat Treatment Protocol
Date of first use/session*

MonthDayYear
Date
Which ALIGN Mat product did you use?*

ALIGN Zen+ALIGN Stealth+Other
How many days per week did you typically use it?*

1-2 days/week3-4 days/week5-6 days/weekDaily (7 days/week)Other
Did you follow a specific routine for your ALIGN Mat use?*

Yes – I usually followed a consistent schedule (e.g., always in the morning, before bed, etc.)No – I used it at varying times, depending on availabilityOther
If you responded Yes, please describe the routine:
Please describe below any additional details about how you used the ALIGN Mat product (only information not asked above):
- minutes per session, sessions per day, device settings, etc
Did you notice any reactions or sensitivities during or after using ALIGN Mat? Please describe how well you tolerated the sessions, including any positive or negative effects you experienced (e.g., comfort, sensations, energy levels, headaches, etc.):
Section 4: Post treatment evaluation

Section B – AFTER Your ALIGN Mat Use Period

Complete this section after a period of ALIGN Mat use that you consider meaningful (for example, after 1 month, 3 months, or more). Please base your answers on how you feel now, following the period you are choosing to report on.

Select a score from 0 to 5 based on your assessment, where 0 indicates the worst possible status and 5 indicates the best.
How long is the period of ALIGN Mat use you are reporting on?*

Less than 1 month1 month2-3 months4-6 monthsMore than 6 monthsOther
Overall Wellness: How would you rate your general sense of wellness?*

0

1

2

3

4

5

0 is Very poor overall wellness, 5 is Excellent overall wellness
Energy Levels: How would you rate your overall energy throughout the day?*

0

1

2

3

4

5

0 is No energy at all, 5 is Full of energy
Mental Clarity: How would you rate your ability to think clearly and stay focused?*

0

1

2

3

4

5

0 is Constant brain fog, 5 is Extremely clear and focused
Physical Recovery: How would you rate your ability to recover from physical exertion or fatigue?*

0

1

2

3

4

5

0 is Very slow or no recovery, 5 is Rapid and complete recovery
Stress Resilience: How would you rate your ability to handle stress effectively?*

0

1

2

3

4

5

0 is Overwhelmed by stress, 5 is Calm and resilient under stress
Mood Stability: How would you rate your overall mood and emotional balance?*

0

1

2

3

4

5

0 is Very unstable or low mood, 5 is Consistently positive and balanced mood
Sleep Quality: How would you rate the quality of your sleep?*

0

1

2

3

4

5

0 is Very poor sleep, 5 is Excellent, restful sleep
Motivation: How would you rate your motivation to complete daily tasks and goals?*

0

1

2

3

4

5

0 is No motivation, 5 is Highly motivated and driven
Anxiety Levels: How would you rate your overall level of anxiety in daily life?*

0

1

2

3

4

5

0 is Extremely anxious or constantly on edge, 5 is Completely calm and free of anxiety
Physical Performance: How would you rate your physical performance or stamina?*

0

1

2

3

4

5

0 is Very poor physical performance, 5 is Excellent physical performance
Mental Recovery: How would you rate your recovery from mental fatigue or overexertion?*

0

1

2

3

4

5

0 is Prolongued mental exhaustion, 5 is Quick and complete mental recovery
Physical Comfort: How would you rate your overall physical comfort in daily life?*

0

1

2

3

4

5

0 is Frequent discomfort of pain, 5 is Completely comfortable and free of physical discomfort
Section 5: Concurrent Therapies Section
Were any other therapies used alongside ALIGN Mat during this period?*

No, ALIGN Mat was used as a standalone therapy.Yes, I continued or added other therapies.
If yes, please specify the type(s) of therapy used (check all that apply):

Chiropractic AdjustmentsAcupunctureLaser TherapyShockwave TherapyE-Stim TreatmentHyperbaric ChambersTraction DevicesRed Light TherapyUltrasoundMicrocurrentTECARPhysical TherapyMassage TherapyStretching / Mobility ExercisesMedications (e.g., NSAIDs, painkillersSupplementsInjections (e.g., corticosteroids)Vibroacoustic TherapyOther
Frequency of Each Therapy Comments (e.g., started mid-treatment, stopped early, etc.)
Additinal notes:
Section 6: Supporting Media (Optional but Encouraged)
Upload before/after photos, x-rays, or video. Annotate films where applicable.
File Upload

Cancelof
Brief explanation of uploaded materials:
Section 7: Conclusion
List any objective findings and provide feedback on whether ALIGN Mat was a positive or negative experience. Will you continue using ALIGN Mat?*
Section 8: Consent & Submission

By submitting this report, I confirm that the information provided in this form reflects my personal experience with ALIGN Mat.

If I have included any identifiable media (such as photos or videos), I consent to its use as part of this submission.

I give permission for my anonymized case to be:
- Reviewed and considered for inclusion in aggregated reports and educational materials.
- Used as a testimonial, without including my name or any identifying information.
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