J9 Massage & Beyond

Emergency Assistance

If this is an emergency, call:

Please be thorough here so we can focus more on treatment at your appointment.

Client Information

First name

Last name

Date of birth

Occupation

Contact Information

Phone number

Email address

Street Address

City

State

ZIP

Emergency Contact

First name

Last name

Phone number

Relationship

Referred By/How did you find me?

Name

Referring Practitioner Name

Referring Practice Name

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

List ALL medical conditions, injuries, accidents, surgeries - and when.

past, recent, and current

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

drug name & condition treated - dose not needed

What else have you tried/who else have you seen regarding this concern/issue? (past and present)

ie myofunctional or physical therapy, orthodontist, periodontist etc PLUS any current/upcoming procedures and treatments

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

What is your goal for seeking treatment?

TMJ/Jaw Concerns

Please check all that apply (past or present)

Have you consulted with or currently under the care of a dental specialist?

ie orthodontist, periodontist, oral surgeon, myofunctional therapist, etc.

Have you experienced dental / oral trauma or recent dental work?

Have you been told you need a mouth/nightguard?

Have you had orthodontia or used another oral appliance?

(not a mouth/nightguard)

Have you received botox injections?

MUST be 2+ weeks to receive manual therapy

Are you aware of any airway issues or mouth breathing?

ie snoring, severe or chronic allergies, tonsil/adenoid removal, etc

NONE OF THE ABOVE - my concerns are not jaw related

note: the above are strong indicators of jaw dysfunction

Provide further details for items noted above, as needed

Any additional details

optional: symptoms, frequency, duration, cause, primary concern or treatment goal

Consent

I understand J9Massage provides corrective bodywork & exercise for resolving problems, and does not diagnose, prescribe, nor is a substitute for medical care.
I understand and agree to the contraindications, 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

USE GOOGLE MAPS and the directions provided when locating the office

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.