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MEDICAL HISTORY
WHY TAKE A MEDICAL
HISTORY?
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Individuals are surviving what used to
be fatal diseases and have more chronic
conditions
Dental treatment may involve
procedures that could place a patient at
risk
DOES EVERY PATIENT NEED TO
HAVE A MEDICAL HISTORY ON
FILE – ABSOLUTELY!!
MEDICAL HISTORY FORMAT
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Interview on blank
form
Commercially
printed form
Custom form for
individual’s office
Basic Information Desired
Similar on all Forms
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Thorough review of the patient’s
medical history(positive responses)
A brief review of systems(c-v,
neurologic, pulmonary,etc.)
Medication list
Other pertinent(surgeries, allergies,etc)
UKCD MEDICAL HISTORY
REVIEW OF SYSTEMS
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Cardiovascular
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Pulmonary
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Hematologic
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Neurologic
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Dermal/musculoskeletal
Endrocrine
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Gastrointestinal
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Genitourinary
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Other
CARDIOVASCULAR
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Congestive heart
failure
Heart attack
Hypertension
Heart Murmur
Mitral Valve Prolapse
Arrhythmias
Coronary Artery
Bypass
Congestive Heart Failure
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Not a disease – clinical syndrome
complex
Uncontrolled? – no elective care
Chair position – difficulty in breathing
Vasoconstrictor – use with caution
Current meds – digoxin?
Heart Attack
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History of occurrence
Status of myocardial muscle
Surgical procedure(cabg, stent
angioplasty)
Medications(anticoag, cardiac meds)
Vasoconstrictor – use with caution
Hypertension
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Controlled
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Medications
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Symptoms
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Vasoconstrictors – use with caution
Heart Murmur
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Type – physiologic or pathologic
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Risk for bacterial endocarditis
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Need for antibiotic prophylaxis
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AHA – Amoxicillin 2 g 1 hour before tx
Mitral Valve Prolapse
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Risk for endocarditis – regurgitation
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Antibiotic prophylaxis
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No regurgitation – no risk
Arrhythmias
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Related to heart failure or ischemic
heart disease
Stress reduction
Pacemaker? – caution with cavitron or
electrosurge
Caution with vasoconstrictor
Coronary Artery Bypass
Surgery
Vasoconstrictors – use with caution
immediately after surgery to prevent
arrhythmias
HEMATOLOGIC
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Blood tranfusions
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Hemophilia
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Taking blood thinner
Blood Tranfusions
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Screen for underlying bleeding disorder
Carriers of blood borne
pathogen(hepatitis, HIVS)
Hemophilia
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Caution during procedures that involve
clotting
Consult with physician about
management
Blood Thinner Medications
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Lab values(PT, INR)
Consult with physician if invasive
procedure involve excessive bleeding
NEUROLOGIC
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Stroke
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Seizures
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Severe Headaches
STROKE
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Physical limitations
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Medications(anticoag)
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Risk for future strokes
SEIZURES
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Last occurrence(controlled)
Stimulus for seizures
Aura
Type of seizure
Medications
Severe Headaches
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Frequency
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Type(vascular vs tension)
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Medications
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Stimuli
PULMONARY
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Asthma
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Allergies
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Tuberculosis
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COPD
ASTHMA
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Type of asthma(mild,moderate,severe)
Precipitating factors
Frequency
Medications
How the attacks are usually managed
ALLERGIES
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Seasonal or environmental
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Medications
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Triggers
Tuberculosis
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Infectivity status
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History of management
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Medications for treatment
ENDOCRINE
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Diabetes
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Thyroid Disease
DIABETES
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Type(type 1 or type 2)
Medications(insulin, oral)
Disease controlled(blood glucose levels)
Dental management – diet, time of
appointments, infection control
THYROID DISEASE
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Type(hypo or hyperthyrodism)
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Medications
GASTROINTESTINAL
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Hepatitis
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Ulcers
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Eating Disorder
HEPATITIS
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Type(A,B,C,D,E,NonA-E)
Medical management
Medications
Liver function/status
Modification of local anesthetic or drug
prescriptions
ULCERS
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Medications
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Prescribing medications
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Active or chronic disease
Eating Disorder
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Type(anorexia, bulimia)
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History(current, past, length of time)
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Management
GENITOURINARY
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Dialysis
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HIV positive
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STD
ADDITIONAL INFORMATION
THAT IS PERTINENT
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Allergies to any drugs or anesthetics
Surgeries
Signs/symptoms undiagnosed disease
List of ALL drugs/medications
Pregnancy
Name of physcian – when was last visit
and why
VITAL SIGNS
ASA CLASSIFICATION
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ASA I – Normal, healthy patient
ASA II – Patient has mild systemic
disease that does not interfere with
daily life
ASA III –Pt. has moderate-severe
disease that may alter daily life
ASA IV – Pt. with severe life
threatening disease
REASONS FOR MEDICAL
HISTORY

Screening device
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Ensure safe management of all patients
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Ensure the safety of all providers