By all legal and ethical standards and practice protocols, it is extremely important to have a proper and complete medical-dental history. Every time you see a patient, this history is relied on to guide you in questions such as type of anesthetic, how the patient withstands treatment, and medical complications. Therefore, the history must be complete for every patient, and an initial blood pressure must be taken. Both must be updated yearly or as needed per the patient’s medical condition and the treatment to be rendered. The history must be signed and dated by the patient or legal guardian and reviewed and signed or initialed by the dentist. At the end of the health/medical history, the patient should sign a simple statement such as: “I hereby acknowledge the medical history is correct and complete and will inform of any future changes.” The history should contain, but not be limited to, the following:

Many times patients do not think taking a small pill such as a baby aspirin (81mg) is important enough to be marked down on the medical history. Additionally, a successful joint replacement without any complications many years ago may seem to be unnecessary information for a patient going to get his or her teeth cleaned. Therefore, with proper questioning, certain medical conditions requiring premedication or other precautions will be uncovered and treated accordingly.

Even though the patient has completed the health history, without investigative questioning, important facets of the patient’s history may be missed.