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Submit Intake Form Here

Please Fill Out Our Patient Intake Form

First name*

Last name*

Email*

Phone

Address

Birthday

Occupation

Do you have any known medical conditions? (e.g., diabetes, hypertension, arthritis) *

Have you had any recent surgeries or hospitalizations?*

Are you currently taking any medications? If yes, please list them.

When did your jaw, neck or head pain first start?

Describe the nature of your jaw pain?*

Where is your jaw pain located? *

Does the pain radiate to other areas? *

On a scale of 0 to 10, how would you rate your pain level at worst, best and now? List in that order

What activities or movements aggravate your jaw pain?*

Are there any activities or movements that relieve your pain?

Do you experience pain while eating or chewing?

Yes

Do you clench or grind your teeth, especially at night?

Grind

Clench

I don't know

Click all that apply

Do you experience difficulty in opening or closing your mouth?

Tightness

Popping/Clicking

Stuck Open or Close

No Difficulty

Pain

Weakness

Click all that apply

Do you have difficulty speaking or swallowing?

Yes

Do you experience headaches along with your jaw pain?

Yes

Do you have neck pain or stiffness?

Yes

Do you experience ear pain or ringing in your ears (tinnitus)?

Yes

Do you have any facial muscle tenderness or fatigue?

Yes

Have you sought any previous treatments for your jaw pain? If yes, what were they?*

Do you engage in activities that might strain your jaw ?

Do you have a high-stress lifestyle or experience frequent stress?

Yes

Other

Do you practice any relaxation or stress management techniques?*

What are your primary goals for seeking physical therapy for your jaw pain?*

Are there specific activities or functions you would like to improve?

Is there any other information you believe is relevant to your jaw pain and treatment?

Thank you for taking the time to complete this questionnaire. Your responses will help us create a personalized treatment plan to address your jaw pain and improve your overall function and well-being

Accessibility Statement for Jaws Physical Therapy

This is an accessibility statement from Jaws Physical Therapy .

Conformance status

The Web Content Accessibility Guidelines (WCAG) defines requirements for designers and developers to improve accessibility for people with disabilities. It defines three levels of conformance: Level A, Level AA, and Level AAA. Jaws Physical Therapy is partially conformant with WCAG 2.1 level AA. Partially conformant means that some parts of the content do not fully conform to the accessibility standard.

Feedback

We welcome your feedback on the accessibility of Jaws Physical Therapy. Please let us know if you encounter accessibility barriers on Jaws Physical Therapy:

E-mail: ajs@jawsPT.com

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