HEALTH HISTORY ASSESSMENT
A health history assessment includes multiple data points that are collected through a written document and an oral interview.The process helps build a rapport with the patient and verifies key elements of the health status. Information is collected and discussed in a location that ensures patient privacy and complies with the Health Insurance Portability and Accountability Act (HIPAA).
Demographic information is any information that is necessary for conducting the business of dentistry. It includes but is not limited to address, date of birth, emergency contact information, phone numbers, and names and addresses of the referring/previous dentist and physician of record.
Vital Signs including temperature, pulse, respiration, and blood pressure provide a baseline or help identify potential or undiagnosed medical conditions.
Physical characteristics of height and weight provide information for drug dosing and anesthesia and indicate risk for medical complications. Disproportionate height and weight also combine as a risk factor for diabetes and other systemic diseases that impact oral health and should prompt the practitioner to request glucose levels for health history documentation.
Social history information such as marital status, children, occupation, cultural practices, and other beliefs might affect health or influence treatment acceptance.
Medical history is the documentation of overall medical health. This information can identify the need for physician consultation or any contraindications for treatment. This includes any mental health diagnosis, cognitive impairments (e.g., stages of dementia), behavioral challenges (e.g., autism spectrum), and functional capacity assessment. It also includes the patient’s level of ability to perform a specific activity such as withstanding a long dental appointment as well as whether the patient requires modified positioning for treatment. Laboratory tests such as A1C and current glucose levels may need to be requested if they are not checked regularly.
Pharmacologic history includes the list of medications, including dose and frequency, which the patient is currently taking. This includes but is not limited to any over-the-counter (OTC) drugs or products such as herbs, vitamins, nutritional supplements, and probiotics. The practitioner should confirm any past history of an allergic or adverse reaction to any products.