Jaw Trigger Point Release Intake Form
Please complete this intake form so the provider can understand your jaw symptoms, history, and treatment needs before your visit.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text
Jaw Symptoms and Visit Details
Reason for Visit / Main Concern
*
Which Jaw Side Is Affected?
*
Left
Right
Both
Not sure
Symptom Onset Date
-
Month
-
Day
Year
Date
Symptom Duration (Days)
Pain Severity
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Pain Quality / Description
Aching
Sharp
Tight
Clicking
Locking
Spasming
Other
What Makes Symptoms Better or Worse?
Relevant Medical History
History of TMJ or jaw issues?
*
Yes
No
Prior treatments tried
Massage
Physical therapy
Dental guard
Medication
Chiropractic
Dry needling
Injection
None
Other
Current medications and supplements
Known allergies or sensitivities relevant to treatment
Relevant medical conditions or injuries affecting treatment planning
Care Planning Notes
What would you like to improve with treatment?
*
Areas of tightness or referred pain
Jaw
Temple
Cheek
Ear
Neck
Shoulder
Head
Other
Additional notes for the provider
Preferred appointment date and time
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Submit
Should be Empty: