Obtaining a Patient’s Health History – Dental Compliance

Maintaining an accurate, complete, and up-to-date patient history file is important to ensure that appropriate treatment is being rendered. Failure to respond correctly to medical conditions disclosed in the patient’s medical history can be dangerous to the patient, and could lead to significant liability exposure for the dentist.

Recommendations and Requirements

• Most state dental boards consider failure to obtain a patient health history prior to dental treatment to be negligence.
• The Centers for Disease Control and Prevention (CDC) recommends latex allergy information to be included in patient health history forms.
• In California, Cal/OSHA requires information about aerosol transmissible diseases (ATDs) such as influenza and tuberculosis to be included in patients health history forms.
• Your liability carrier will have strict contract specifications in place to ensure you are following recommendations for patient health histories. Contact your liability carrier for their recommendations, including health history forms.

Health History Forms

Patient health histories should be taken initially, at the first visit, and updated at each subsequent visit, with patients signing and dating each time. Most liability carriers will recommend that the following medical information be included on health history forms:

• Conditions requiring premedication
• History of infectious disease, including ATDs
• History of other illnesses
• History of major surgeries
• Current medical problems or concerns
• Existing medications
• Allergies, including latex
• Tobacco, drug, or alcohol use
• Name and contact information of the patient’s primary care physician (for premedication) and specialist (treating current medical problem)
• Blood pressure reading and pulse rate

For a returning patient, show the patient the previous signed form and ask for any updates since the last visit. Dental staff should review the health history information with the patient. Contact your liability carrier for additional steps to take if concerns arise about treating a patient.

Since 1992, OSHA Review, Inc. has provided dental professionals with comprehensive programs to support regulatory compliance and infection control. We are a registered continuing education provider in the state of California, specializing in Dental Practice Act, infection control, and OSHA training.