TMJ Intra Oral Integration

This form is intended for clients who have received a TMJ Intra-Oral session only

First name

Last name

What brought you in for TMJ Intra Oral work?*

TMJ & Related Symptoms (check all that apply)*

Jaw pain or tenderness

Clicking, popping, or grating sounds when opening/closing mouth

Limited range of jaw movement or locking

Headaches (tension or migraines)

Facial pain or soreness

Pain while chewing

Neck and shoulder tension

Teeth grinding or clenching

The feeling that your teeth don't align properly

Difficulty swallowing

Dental surgery

Trauma/Injury to the face

Emotional tension in jaw (clenching in response to stress)

How long have you been experiencing these symptoms?*

Are they constant or do they fluctuate?*

Have you been diagnosed with TMJ disorder?*

Yes

Do you wear a night guard?*

Yes

Do you experience high levels of stress in your daily life? If so, what are some triggers for you?

How would you describe your relationship to touch?

Comfortable

Neutral

Sensitive/guarded

Prefer minimal touch

Did you notice any of the following during the session?

Sensations (warmth, tingling, tension, release)

Emotions or memories surfacing

Nervous system responses (sighing, tears, twitching, relaxation)

How did you feel about the quality of Non-Agenda touch?

It felt safe and allowed for my body open up slowly

It felt supportive and was just enough

I desired more pressure

Did you find tracking sensation while receiving this work was helpful? Please explain.

What did you find helpful during your session? Please explain

How did you feel immediately after your session? Please explain.

Within 24-72 hours, did you notice any changes in your symptoms, overall body tension, emotional state, sleep or anything unexpected?

Anything else you'd like to share about your experience?

Please share any final notes and feedback on your experience with Flutura as a practitioner:

STILLPOINT WITHIN MASSAGE & BODYWORK

LOCATED INSIDE:

THE HEALING CO MASSAGE & ACUPUNCTURE

4705 W 38TH AVE

DENVER, CO 80204

(608) 438-7284

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