Berson Dental TMJ Form

  • 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. 

  • Date*
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  • Format: (000) 000-0000.
  • SEX:*
  • MARITAL STATUS:*
  • CURRENT EMPLOYMENT STATUS:*

  • WHO REFERRED YOU?

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

  • Rows
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  • History

    Please refer back to your main problem(s) and answer the following questions.
  • B. What caused the onset of this condition?*
  • C. How fast did the condition arise?*
  • D. How has the condition changed since it began?*
  • Rows
  • HOW OFTEN DO YOUR SYMPTOMS OCCUR?*
  • WHEN YOUR SYMPTOMS OCCUR, HOW LONG DO THEY LAST?*
  • WHEN ARE YOUR SYMPTOMS WORSE?*
  • WHICH WORD GROUP BEST DESCRIBES THE PATTERN OF YOUR PAIN?*
  • HAS ANYONE IN YOUR FAMILY HAD A SIMILAR CONDITION?*

  • 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. 
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  • EFFECT OF PAIN ON DAILY LIVING:

  • How would you rate your facial/head pain at the present time using a 0 to 10 scale where 0 is "no pain" and 10 is "pain as bad as could be." Select the most accurate number.*
  • In the past 6 months, on the average, how intense was your pain? Please use the scale below.*
  • Please indicate how much facial/head pain has changed your ability to take part in recreational, social and family activities where 0 is "no change" and 10 is "extreme change."*

  • PAST MEDICAL HISTORY:

  • Are you otherwise in good health?*
  • Are you being treated for anything other than your current condition?*
  • Rows
  • Rows
  • PLEASE NOTE HOW MUCH YOUR "CHIEF COMPLAINT" DISTURBS YOUR SLEEP BY CHECKING THE NUMBER ON THE DIAGRAM:*

  • Lifestyle

    Please answer each question by selecting the box by your usual level.
  • Activity*
  • Exercise*
  • Social Activity*
  • Eating*
  • Caffeine Beverages*
  • Take Vitamins*
  • Alcoholic Beverages*
  • Smoke Tobacco*
  • Recreational Drugs*

  • 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:
  • Today's Date*
     - -
  • Should be Empty: