1. MEDICAL HISTORY

2. WHY TAKE A MEDICAL HISTORY? 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

3. DOES EVERY PATIENT NEED TO HAVE A MEDICAL HISTORY ON FILE – ABSOLUTELY!!

4. MEDICAL HISTORY FORMAT Interview on blank form Commercially printed form Custom form for individual’s office

5. Basic Information Desired Similar on all Forms 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)

6. UKCD MEDICAL HISTORY

7. REVIEW OF SYSTEMS Cardiovascular Hematologic Neurologic Gastrointestinal Pulmonary Dermal/musculo- skeletal Endrocrine Genitourinary Other

8. CARDIOVASCULAR Congestive heart failure Heart attack Hypertension Heart Murmur Mitral Valve Prolapse Arrhythmias Coronary Artery Bypass

9. Congestive Heart Failure Not a disease – clinical syndrome complex Uncontrolled? – no elective care Chair position – difficulty in breathing Vasoconstrictor – use with caution Current meds – digoxin?

10. Heart Attack History of occurrence Status of myocardial muscle Surgical procedure(cabg, stent angioplasty) Medications(anticoag, cardiac meds) Vasoconstrictor – use with caution

11. Hypertension Controlled Medications Symptoms Vasoconstrictors – use with caution

12. Heart Murmur Type – physiologic or pathologic Risk for bacterial endocarditis Need for antibiotic prophylaxis AHA – Amoxicillin 2 g 1 hour before tx

13. Mitral Valve Prolapse Risk for endocarditis – regurgitation Antibiotic prophylaxis No regurgitation – no risk

14. Arrhythmias Related to heart failure or ischemic heart disease Stress reduction Pacemaker? – caution with cavitron or electrosurge Caution with vasoconstrictor

15. Coronary Artery Bypass Surgery Vasoconstrictors – use with caution immediately after surgery to prevent arrhythmias

16. HEMATOLOGIC Blood tranfusions Hemophilia Taking blood thinner

17. Blood Tranfusions Screen for underlying bleeding disorder Carriers of blood borne pathogen(hepatitis, HIVS)

18. Hemophilia Caution during procedures that involve clotting Consult with physician about management

19. Blood Thinner Medications Lab values(PT, INR) Consult with physician if invasive procedure involve excessive bleeding

20. NEUROLOGIC Stroke Seizures Severe Headaches

21. STROKE Physical limitations Medications(anticoag) Risk for future strokes

22. SEIZURES Last occurrence(controlled) Stimulus for seizures Aura Type of seizure Medications

23. Severe Headaches Frequency Type(vascular vs tension) Medications Stimuli

24. PULMONARY Asthma Allergies Tuberculosis COPD

25. ASTHMA Type of asthma(mild,moderate,severe) Precipitating factors Frequency Medications How the attacks are usually managed

26. ALLERGIES Seasonal or environmental Medications Triggers

27. Tuberculosis Infectivity status History of management Medications for treatment

28. ENDOCRINE Diabetes Thyroid Disease

29. DIABETES Type(type 1 or type 2) Medications(insulin, oral) Disease controlled(blood glucose levels) Dental management – diet, time of appointments, infection control

30. THYROID DISEASE Type(hypo or hyperthyrodism) Medications

31. GASTROINTESTINAL Hepatitis Ulcers Eating Disorder

32. HEPATITIS Type(A,B,C,D,E,NonA-E) Medical management Medications Liver function/status Modification of local anesthetic or drug prescriptions

33. ULCERS Medications Prescribing medications Active or chronic disease

34. Eating Disorder Type(anorexia, bulimia) History(current, past, length of time) Management

35. GENITOURINARY Dialysis HIV positive STD

36. ADDITIONAL INFORMATION THAT IS PERTINENT 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

37. VITAL SIGNS

38. ASA CLASSIFICATION 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

39. REASONS FOR MEDICAL HISTORY Screening device Ensure safe management of all patients Ensure the safety of all providers