La Vie Spa & Salon

La Vie's Hours
Monday	9am - 8pm
Tuesday	9am - 6pm
Wednesday	9am - 6pm
Thursday	9am - 8pm
Friday	9am - 6pm
Saturday	9am - 4pm
Sunday	Closed

TMJ (Temporal Mandibular Joint) - Services

TMJ (Temporal Mandibular Joint) - 35 (30 Minutes)

To Save Time Please Fill Out This Form Prior To Appointment. Thank You!

Name:
Email Address:
Have you ever recieved a professional massage or Reflexology?	Yes No
Date of last massage/reflexology
Are you currently on any medication?	Yes No
Please list current medications, including aspirin, ibuprofen, etc.
What do you expect from your massage or reflexology today?
Medical History Surgeries? Year? Treatment Recieved?
Accidents?
Health History.. Excercise	None Moderate Daily Weekly Heavy
Work Activity?	Sitting Standing Light Labor Heavy Labor
Health History Smoking, Packs a day?
Alcohol, Drinks/wk
Caffeine, cups/day
Stress/ Reason?
Hepatitis A, B or C HIV/AIDS?	Yes No
Allergies?	Yes No
Other	Yes No
Lupus	Yes No
Jaw Pain/TMJ	Yes No
Stiffness	Yes No
Spasms/Cramps	Yes No
Headaches/Head Injuries	Yes No
Painful Feet	Yes No
Lower Back/Hip/Leg Pain	Yes No
Sprains/Strains	Yes No
Arthritis	Yes No
Bone or joint disease/injury?	Yes No
Tendonitis	Yes No
Bursitis	Yes No
Broken/Fractured Bones	Yes No
Circulatory Heart condition	Yes No
Allergies	Yes No
Sinus Problems	Yes No
Breathing Difficulty	Yes No
Lymphedema	Yes No
High Blood Pressure	Yes No
Blood Clots	Yes No
Varicose Veins	Yes No
Reproductive	Pregnant PMS Other
Other	Yes No
Skin Allergies	Yes No
Warts	Yes No
Athletes Foot	Yes No
Rashes	Yes No
Other	Yes No
Nervous System Numbness/Tingling	Yes No
Fatigue	Yes No
Sleep Disorders	Yes No
Chronic Pain	Yes No
Other	Yes No
Digestive Irritable Bowel Syndrome	Yes No
Gas/ Bloating	Yes No
Diverticulitis	Yes No
Other	Yes No
Moderate Discomfort	Yes No
Tolerable but intense discomfort	Yes No
Depression	Yes No
Eating Disorders	Yes No
Diabetes	Yes No
Cancer/Tumors	Yes No
Slight Sensitivity Or Superficial Tension?	Yes No
Others...... Corn	Yes No
Hammer Toe	Yes No
Bunion	Yes No
Ingrown Nail	Yes No
Changes in Tissue Texture	Yes No
Explain any OTHERS, in above questions.

La Vie Spa & Salon

La Vie's Hours

TMJ (Temporal Mandibular Joint) - Services

TMJ (Temporal Mandibular Joint) - 35 (30 Minutes)