• The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • Client Intake Form

  • Date
     - -
  • Format: (000) 000-0000.

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • Medical History

  • Please mark any conditions that are current or relevant to your care.

  • General Conditions:
  • Respiratory and Circulatory:
  • Digestive:
  • Nervous System & Sleep:
  • Skin and Other:
  • Have you ever received therapeutic massage & bodywork for a specific concern or injury?

  • You don't need to have all the answers - share only what feels relevant.

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • TMJ & Musculoskeletal Questionairre

    This information will maximize the safety and effectiveness of your evaluation and/or treatment. Your answers and selections will be the building blocks to your treatment plan on the first and follow-up visits. Please carefully take your time filling out this information. Below, make selections that apply to you.
  • Jaw Symptoms
  • Muskuloskeletal Conditions
  • Frequency
  • At what time of day is the pain at its worse?

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • TMJ & Musculoskeletal Questionairre (Continued)

  • Do you have any of the following habits?
  • Please select if you have any of the following.
  • Has your mouth or jaw ever locked?
  • Are any teeth painful or sensitive?
  • Have you had any teeth removed?

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • TMJ & Musculoskeletal Questionairre (Continued)

  • Do you hold your head in a particular position other than neutral?
  • Do you have stiffness on waking, pain with function that decreases as the day goes by?
  • Have you noticed any voice changes?
  • Do you breathe through your nose?
  • Do you breathe through your mouth?
  • Place one hand on your chest, and one on your upper abdomen. Pay attention to your breathing. Does your hand on your chest rise more when breathing, or the hand on your upper abdomen?
  • Do you wear a dental splint?
  • Have you seen a dentist for your symptoms?
  • Are there any activities/hobbies/self-care/ or work-related duties you are unable to perform because of your symptoms?
  • How do you think you learn best? (Check all that apply.)

  • General Musculoskeletal Questionairre

    Check all that apply.
  • Head Symptoms
  • Neck/Pec Symptoms
  • Arms & Hands Symptoms
  • Shoulder Symptoms
  • Mid-Back Symptoms - Tightness, Pain, or Spasms?
  • Abdomen/Pelvis Symptoms - Tightness, Pain, or Spasms?

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • Client Informed Consent

  • 1) I give permission to receive massage & bodywork therapies.

    2) I understand that therapeutic massage is not a substitute for traditional medical treatment.

    3) I understand that the massage & bodywork therapist does not diagnose illness or injuries or prescribe medications.

    4) I have clearance from my physician to receive massage therapy.

    5) I understand the risks associated with massage and bodywork therapy include, but are not limited to:

    ·         Superficial bruising

    ·         Short term muscle soreness

    ·         Exacerbation of undiscovered injury

    6) I understand the importance of informing my therapist of all medical conditions and medications I am taking, and to let the massage therapist know about any changes to these. I understand that there may be additional risks based on my physical condition.

    7) I understand that it is my responsibility to inform my massage therapist of any discomfort I may feel during the massage session so she can adjust accordingly.

    8) I understand that I or the therapist may terminate the session at any time.

     

    By my electronic signature below, I agree to the Informed Client Consent Form.

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • Payment Policy

    • Payment for treatment is always collected before the session begins.
    • Accepted payment methods are Venmo, Zelle, HSA, and cash.

     

    By signing below, I agree to the Payment Policy.

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • Short Notice Cancellation Policy

  • We know your time is valuable, and ours is too. Out of respect for our staff and our other clients, we ask that you give us at least 24-48 hours of notice if you need to cancel an appointment. The sooner the better. Please leave a message at 848-444-1626 at any time to notify us if you need to cancel or reschedule. Text messages are welcome.

     

    ·  Appointments cancelled without atleast 24 hours notice will incur a $80 cancellation fee that must be paid prior to your next visit.

     

    · If someone books and shows up for treatment during the time block of your missed appointment that day, you will be refunded the $80 cancellation fee.

     

    By my electronic signature below, I agree to the Short Cancellation Policy.

  • The Jaw Remedy

    Advanced TMJ Massage, Bodywork Therapies, & Self-Care

  • Late Policy

  • Out of respect for everyone to be seen at their scheduled time, we have created this late policy. 

     

    ·  If you are x amount of minutes late, that will be x amount of minutes less during your treatment session.

    · We will always try to accomadate the full length when possible, for example, if there is enough time between the next scheduled appointment.

    · The price of the treatment will remain at full price.

    By my electronic signature below, I agree to the Late Policy.

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