(425) 998-6998

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  • Thur:7:00am–1:00pm
  • Fri:7:00am–12:00pm

Dental 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:


Dental History

Previous Dentist:

Date of last dental visit(if not here):

What problems have you had with past dental treatments?:


How do you feel about the appearance of your teeth?:

Do your gums bleed when you brush?:

Yes No  

Have you had any periodontal treatment?:

Yes No  

Have you had facial or gum swelling?:

Yes No  

Do you experience any clicking or popping in your jaw?:

Yes No  

Are you aware that you clench or grind your teeth?:

Yes No  

Do you have headaches?

Yes No  

Do you have a nightguard, splint, snore guard?:

Yes No  


I often catch food between my teeth:

Yes No  

I would like fresher breath:

Yes No  

I have or have had jaw pain (TMJ):

Yes No  

I have problems eating:

Yes No  

I have had orthodontics:

Yes No  

I feel that my teeth have shifted:

Yes No  

I avoid brushing part of my mouth due to pain:

Yes No  

My mouth often feels dry:

Yes No  


Do you use a mechanical (electric) toothbrush?:

  Yes   No  

If yes, which brand?:


Do you use flossing aids (holder, threaders, etc.):

Yes No  

Do you use an oral irrigation device (Waterpik)?:

Yes No  

Do you use fluoride treatments or supplements at home?:

Yes No  

If so, which brand?:

Do you use mouthwashes or oral rinses?:

  Yes   No  

If so, which brand?:

Have you ever had any complications from an extraction or dental treatment?:

  Yes   No  

If yes, please specify:


Have you been bothered by?

Tooth pain

Dry mouth

Uneven bite

Tooth color/appearance

Rough / sharp tooth surface

Bad breath


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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!

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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.

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Cooley Smiles, 4100 Factoria Blvd SE, Bellevue, WA, 98006-1262 - Associated Words: Dentist Bellevue WA, Cosmetic Dentist Bellevue WA, Dentist Bellevue WA, (425) 998-6998, www.cooleysmiles.com, 2/16/2019