ADA Accessibility Information


WEO Media

Medical History Form


The information provided on this form is important to your dental health. Please complete all of 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:

Occupation / Recreation

Occupation (if any):

Employer (if any):

Recreational activities:


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

WEO Media - Dental Marketing
8625 SW Cascade Avenue, Suite 300
Beaverton, OR 97008

Call today 888-788-4670
Support 888-788-4670

Read our reviews on Google Follow us and read reviews on Facebook Learn about us on Linked In Watch informative videos on our Youtube channel Follow us on Instagram Follow us on Twitter

Book one of our Marketing Consultants to speak at your event.

icon speaker
Tell us about your event

Copyright © 2011-2022 WEO Media. All rights reserved.  Sitemap
Contact Support @ WEO Media | Website Edits, Billing Questions, Etc.
Do you need help? Contact WEO Media's most excellent support team. They can help you with all your dental website needs. Website edits, billing questions, etc.
WEO Media, 8625 SW Cascade Avenue Suite 300, Beaverton, OR 97008-7121 - 888-788-4670 - - 8/10/2022 - Tags: Dental Marketing -