La Vie's Hours

Monday9am - 8pm
Tuesday9am - 6pm
Wednesday9am - 6pm
Thursday9am - 8pm
Friday9am - 6pm
Saturday9am - 4pm
SundayClosed

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.