J9 Massage & Beyond

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Date of birth

Occupation

Contact Information

Phone number

Email address

Address

Emergency Contact

First name

Last name

Phone number

Relationship

Referred By

Name

Referring Practitioner Name

Relationship

Referring Practice Name

Office Address

Referring Practice Address

Referring Practice Phone Number

I consent to my therapist communicating relevant findings with my referring or collaborating healthcare provider(s) for the purpose of coordinating care.

e-signature

Medical History - please type "none", where applicable

Have you had a professional massage before?

Yes No

Have you had intraoral massage before?

Yes No

Do you have any pre-existing medical conditions?

Example: Acid reflux, allergies, diabetes, heart conditions, high blood pressure, etc

What medications are you taking (if any) and for what conditions?

List all past or recent injuries, accidents, and surgeries - and when.

include any upcoming procedures

Lifestyle

Do you exercise?

Regularly Occasionally No

How much water do you drink?

< 4 cups/32 oz 4 cups/32 oz - 8 cups/64 oz 8 cups/64 oz/Half gallon +

How are your stress levels?

High Moderate Low

Reason for Visit

Primary Concerns

Jaw/TMJ issues

Neck

Shoulder

Back

Hip/pelvis

Headaches

Knee/calf/foot

Postural Imbalance

Unsure / other

TMJ/Jaw Concerns

Related History

Dental / oral trauma or recent dental work? past or present

Yes No

Past / presently under the care of a dental specialist? ie orthodontist, periodontist, oral surgeon, myofunctional therapist, etc.

Yes No

Airway issues / mouth breathing? past or present

Yes No

Orthodontia or other oral appliance? past or present

Yes No

Receive botox injections? past or present

Yes No

Told you need a mouth / night guard? past or present

Yes No

Any additional details

optional: symptoms, frequency, duration, cause

Consent

I understand J9Massage provides corrective bodywork & exercise for resolving problems, and does not diagnose, prescribe, nor is a substitute for medical care.
I agree to the terms, conditions, cancellation/payment/office policies: https://www.j9massageandbeyond.com/faq
I understand the 24 hour cancellation and sick policies.
I will not receive massage if I am sick or may be getting sick.
I consent to receive email and SMS communications.
I will inform the practitioner of any changes in my condition.
I consent to receive orthopedic massage treatment and/or intraoral manual therapy.
I confirm that the information provided is accurate to the best of my knowledge.

Name

e-signature

Date

Your information will be encrypted.

Jennine "J9" Amato MA LMT #659

Manual Therapist, J9 Massage & Beyond

--- Chronic Pain, Posture, & TMJ Relief --- I help people move beyond chronic pain, postural imbalance, and TMJ dysfunction through personalized, results-driven bodywork. I specialize in intraoral (jaw) massage, corrective bodywork, exercise, myofunctional, and craniosacral therapy to relieve jaw pain, migraines, headaches, and neck, shoulder, back, and postural dysfunction.