Essentials of medical history-taking in dental patients

The main parts of a patient history are well established. It is important that practitioners follow a recognized systematic scheme of enquiry to minimize the risk of missing important information.

All dental practitioners are familiar with the main components of the history-taking process. The purpose of this paper is to revise those areas and add some context to some of the more important aspects and provide updates where appropriate.

The presenting complaint may best be expressed in the patient's own words. The information presented can then be summarized by the clinician.

A chronological approach should be used. As a minimum, the history of a presenting complaint should include the following:

In dental practice, the presenting complaint is often pain. A generic scheme of questions to assess the nature and severity of a patient's pain is shown as follows:

Generic questioning regarding major systems such as the cardiovascular or respiratory systems is often the way practitioners start obtaining a medical history. Questioning should then focus on specific disorders,1 such as asthma or other respiratory disorders, diabetes mellitus, epilepsy, hypertension or other cardiovascular problems (stroke, myocardial infarction, angina), hepatitis or jaundice. Positive responses should be followed-up by an assessment of the severity of the disorder, treatments used and their efficacy. Previous problems with the arrest of haemorrhage are worth specific enquiry. Table 1 highlights situations where the arrest of haemorrhage may be affected and implications for management.