Berson Dental TMJ Form Logo

  • Health History

  • INSTRUCTIONS: This questionnaire will help us to understand your problem and should be completed BEFORE your first appointment. We know that this form is long and will take time but please read and answer every question carefully so that we can make the correct diagnosis. Try to answer these questions by YOURSELF, without any assistance from anyone else if possible. 

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  • WHO REFERRED YOU?

  • DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING?

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  • History

    Please refer back to your main problem(s) and answer the following questions.
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  • Pain Experience

    Complete this section only if PAIN is one of your chief complaints. Some of the groups below contain words that describe your PRESENT pain. Select only ONE word in each group which best describes how it feels. If a group does not apply to you, leave it out. 

  • EFFECT OF PAIN ON DAILY LIVING:

  • PAST MEDICAL HISTORY:

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  • Lifestyle

    Please answer each question by selecting the box by your usual level.

  • CONSENT FOR REPORTS:

    TO THE BEST OF MY KNOWLEDGE, ALL OF THE ABOVE INFORMATION IS CORRECT AND I GIVE PERMISSION TO SEND A WRITTEN REPORT TO REFERRING AND TREATING DOCTORS BASED ON THE INFORMATION PROVIDED:
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