(425) 998-6998

  • Mon-Wed:7:00am–5:00pm
  • Thur:7:00am–1:00pm
  • Fri:7:00am–12:00pm

Medical History Form


The information provided on this form is important to your dental health. Please complete all of the questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.


The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

Contact Information

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Patient Email: *

Home phone: *

Work phone:

Cell phone:


Preferred way to contact: *

Home phone Cell phone Email Work phone  


Date of birth: *


Patient Gender: *

  Male   Female  

Emergency Contact Name:

Emergency Contact Phone:


Health History

Primary Medical Doctor:

When was your last physical?

Date of last dental visit (if not here):

Clinic / Doctor:

Emergency Contact/Phone Number:

Preferred Pharmacy:

Do YOU (Not family members) have any of these conditions?



Yes No  

High blood pressure

Yes No  

MS, stroke, seizures

Yes No  

High levels of cholesterol

Yes No  

Asthma or breathing disorders

Yes No  

Allergy - Seasonal

Yes No  


Yes No  

Sinus conditions

Yes No  

Weight loss / gain

Yes No  

Skin - Rosacea

Yes No  


Yes No  


Yes No  

Communicable diseases

Yes No  


Yes No  


Yes No  

Thyroid trouble

Yes No  

Rheumatoid arthritis

Yes No  

Shingles / herpes zoster

Yes No  

Sleep disorders

Yes No  

Ulcers or kidney disorders

Yes No  


Are you pregnant?

Yes No  

Do you have a history of cancer?

Yes No  

If so, what kind of cancer?


Please list any medications and supplements you are currently taking:

Please list any known medications you have had an allergic reaction to:


Have you been diagnosed with?

Gum disease


Tooth infection


Do you have a family history of?

Heart disease




Have you had?

A tooth or jaw injury

Periodontal treatments

Orthodontic treatment (braces, etc)

Root canal procedure

Oral surgery


Are you bothered by?

Tooth pain

Dry mouth

Uneven bite

Tooth color/appearance

Rough / sharp tooth surface

Bad breath


Social History

Do you live alone?

Yes No  

Do you smoke?

Yes No  

If so, number of packs/day:

Do you consume alcohol?

Yes No  

If so, number of drinks/day:


It may take a moment to submit your information. Please wait for a confirmation message.


A Commitment to Patient Education & Preventive Care

The best preventative care and oral health comes from educating patients on what these mean. The more our patients know about the health of their teeth the better they are able to take care of them. They are also better able to make decisions on procedures they might, or might not need. Patients should feel free to ask our dentists and staff any dental questions they may have.

Patient education goes hand in hand with preventative care. We arm patients with the tools needed to best maintain their teeth and overall oral health. This helps prevent issues that can occur between checkups and helps avoid more extensive dental procedures down the road.

As a patient, three things stand out to me about Cooley Smiles - the great quality dental work, the cleanliness of the facility and thorough follow up. These are major differentiators that I look for in dental providers and to-date, I've always been satisfied with my experience. Thanks for the great patient care, Cooley Smiles team!

Join Our
Conversations on:

Cooley Smiles -
4100 Factoria Blvd SE, Suite C Bellevue, WA 98006-1262
- (425) 998-6998

This cosmetic dentistry website is for informational use only. The content within these pages should not be perceived as formal advice, nor does the understanding constitute a formal relationship. ©2011 Cooley Smiles Family and Cosmetic Dentistry - Our Cosmetic Dentists serve patients in Bellevue, Mercer Island, Factoria, and Issaquah, Washington and surrounding communities.

Copyright © 2012-2019 Cooley Smiles and WEO MEDIA. All rights reserved.  Sitemap | Links | Privacy Policy
Cooley Smiles, 4100 Factoria Blvd SE, Bellevue, WA, 98006-1262 - Related Phrases: Dentist Bellevue WA \ Cosmetic Dentist Bellevue WA \ Dentist Bellevue WA \ (425) 998-6998 \ www.cooleysmiles.com \ 3/25/2019