(928) 282-5964 Sedona, AZ
Dental History
Name *
Do your gums bleed when you brush or floss? *
Are your teeth sensitive to cold, hot, sweets or pressure? *
Does food or floss catch between your teeth? *
Is your mouth dry *
Have you had any problems associated with previous dental treatment? *
Have you ever had orthodontic (braces) treatment? *
Have you had any periodontal (gum) treatments? *
Is your home water supply fluoridated? *
Are you currently experiencing dental pain or discomfort? *
Do you have any clicking, popping or discomfort of the jaw? *
Do you have earaches or neck pains? *
Do you brux or grind your teeth? *
Do you have sores or ulcers in your mouth? *
Do you wear dentures or partials? *
Do you participate in active recreational activities? *
Have you ever had a serious injury to your head or mouth?
When it comes to your oral health, do you prefer to be proactive? Someone who likes to avoid complications? Who would rather take care of an issue today instead of letting it worsen over time which might cost more time, visits, money and/or pain to fix down the road?
Do you consider yourself more of a reactive person - someone who would rather wait to deal with any issues after they develop, even if that means costing you more time, visits, money and/or pain to fix down the road? *
Date of your last dental exam:
Date
Date of last dental x-rays:
Date
Name of previous Dentist or Practice?
Previous Dentist City:

To the best of my knowledge, the questions on this form have been accurately answered.  I understand that providing incorrect information can be dangerous to my (or patient’s) health.  It is my responsibility to inform the dental office of any changes in status.

Today's Date *
Date
Signature *
120 Northview Rd #2
Sedona, AZ 86336
(928) 282-5964
Mon - Thur
8:00am to 4:00pm