Craniofacial Therapy Intake Form
Please complete this form to help us understand your craniofacial therapy needs.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Primary Concern or Reason for Visit
*
Current Symptoms
*
Jaw pain
Headaches
Facial swelling
Difficulty chewing
Clicking or popping jaw
Other
How long have you been experiencing these symptoms?
*
Less than 1 month
1–6 months
6–12 months
Over 1 year
Have you received any previous treatment for this condition?
No
Yes, physical therapy
Yes, medication
Yes, surgery
Other
Please list any current medications
Do you have any allergies?
*
No
Yes, medication allergies
Yes, food allergies
Yes, other allergies
Please provide any additional relevant medical history
Submit
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