Personal Information

Emergency Contact Name and Number

Are you taking any medications?

No Yes

If yes, please provide name and use.

Are you pregnant? if so, how many months?

Any allergies? (oils, lotions, nuts, fruit, skin, etc.)

areas of broken skin? e.g. rash or wounds

Recent injuries or medical procedures in the past 2 years? if so, please explain.

What symptoms are you currently experiencing? Which side is affected or is it bilateral?

When did your symptoms start?

When do you feel pain? Morning, afternoon, evening? With eating or opening wide? When stressed?

What have you tried to relieve your symptoms?: Massage, heat, cold, Botox, nightguard, surgery?

What has helped your symptoms? What did not help your symptoms?

Do you have any clicking or popping? Any pain with it?

Any restrictions in opening your mouth?

Does your jaw ever lock open or closed?

Any clenching or grinding at night?

Do you notice any clenching or grinding during the day? During times of stress or concentration? During times of relaxation like days off or vacations?

Do you have headaches or migraines? Where are they located? Bilateral or one side?

Do you have any neck pain or upper trap pain?

Are you comfortable receiving intra oral massage?

Do you clench your teeth? When? Chew gum? Bite nails? inside of cheek? Chew pens?

Do you sleep on your stomach?

Medical history

Dental History

History of Extensive Dental Work Wisdom Teeth Removal Orthodontic Treatment (Duration?) Use of a Palatal Expander

Name of Dentist- permission to communicate with him or her?

Any additional information that I should be aware of?

Please take a moment to read the following information:

I understand that massage therapy is not a substitute for medical examination, diagnosis, or treatment. I acknowledge that it is my responsibility to consult a physician, chiropractor, or other qualified medical professional for any physical or mental condition I am aware of. I affirm that I have disclosed all known medical conditions and answered all health-related questions truthfully. I agree to inform my practitioner of any changes to my health or medical history, understanding that failure to do so releases the practitioner from any liability resulting from undisclosed conditions. I understand that any inappropriate behavior—including illicit or sexually suggestive remarks or advances—will result in the immediate termination of the session, and I will be responsible for the full payment of the scheduled appointment.

I also acknowledge that I will be charged the full session rate of $120 for missed appointments or appointments canceled with less than 24 hours' notice, except in the case of emergencies* subject to review. This fee will be due in full within three (3) days of the missed or late-canceled appointment.

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