Countersignature Child Medical History Made Easy

Patient Medical History Form (PDF) - Dental Boutique - Dentalboutique

hello everybody andrea trusty here with dental health tutoring this is actually a question from a YouTube commenter which is awesome her question was how do you properly go through a medical history and what types of questions to ask and this is an amazing question because in some offices the medical histories can be quite long and in some they can be quite short and it's not something they train you on per se other than your maybe first semester second semester in school and and of course through clinic but things are different when you're in clinic because you have three hours for that whole appointment whereas in a dental office you have 5-10 minutes right so it's good to kind of know what questions to ask further because I've been in the dental field for about 13 years now and sometimes I'm spending a good solid ten minutes half an hour on a medical history whereas other times I'm looking for maybe a second or two and that's it so it's good to kind of have an idea especially when you're first getting started because you may not know the questions to ask or what to look for so first and foremost with the medical histories if the patient answers yes to anything you need to ask further questions so a good example is a lot of people do answer yes to things that they may not have had - so for example I had a patient the other day there's a question on most medical history forms that say that says are you presently under the care of a physician and a lot of patients say yes because what they think that means is are they being seen by a doctor at least every year but that's not actually what that means so that question means are they seeing the doctor every month every two months do they have to go through tests you know that is what that means so if the patient actually does circle yes and they are under their doctor's care you need to ask more questions because if there's their doctor every three months there's a reason for that right it could be because they have some kind of a sickness and the doctor isn't sure what it is it could be because there and a uncontrolled diabetic and the patient just doesn't take care of themselves properly so the doctor is monitoring them over time it could be because the patient has low iron that seems to be a very common one where they're seeing the doctor every three months for either some iron shots or to check their iron levels so there's many different reasons why a patient may be seeing a doctor more often than once per year so if the patient circles yes you need to ask further questions you can't just simply say oh okay and then move on you need to know why they are seeing the doctor so often another one is where there's a question that says are you currently taking any medications if the patient says yes but isn't sure of the medications and that's a very common one you need to ask them further questions because you need to know what the medications are and you need to know why they are taking them because there are so many different types out on the market where they could be taking a medication too let's taste stop smoking but that same med could also be used for something else so even if you see a medication that you think you know what it's for always always asked you know and sometimes the patients have no idea sometimes the patients will say to you well I'm taking this this and this but I don't know why well they should know but but sometimes they just simply don't know what so then you have to look it up on the internet and it will typically give you reasons why people are taking that medication so then you could say to your patient well are you taking because you are a diabetic are you taking it it could also be used as an antidepressant you know something along those lines so you need to know why they're taking it and then they may say to you well not a diabetic I'm depressed so you know what it's probably for that or you you may have found out something new you know if they say well if that medication is for depression well I am depressed so maybe I'm taking it for them but perhaps on the rest of the medical history it doesn't mention anywhere that they're depressed right so it's it's it's nice to put things together because sometimes patients don't know how to fill out the medical history so that's why it's so important that you know the questions to ask another a common one seems to be a question about mental health so if the patient circles yes I am under the care for mental health you need to ask what for because it could be because they're anxious it could be because they're they're being looked at you know it could be because they're depressed it could be because they're it's a phrenic bipolar there are many different reasons why somebody may be under mental healthcare you know I've seen patients where they're under mental healthcare they're seeing a therapist because they're anxious but that's it or I've had some patients that are under the mental healthcare they're seeing a therapist because they're depressed and bipolar and schizophrenic you know so it's good to know all of those things another common question is have you had any seizures if somebody circles yes this is a very important question because there are several things that know you have to ask first you have to say when was your last seizure if they say it happened 30 years ago that's not something to be concerned about if they say it happened yesterday then you also need to ask well how often does this happen if they say I have a seizure every week that's pretty serious if if they say well I did have a seizure yesterday but I didn't have one for 10 years you know it's still something to be concerned about because they just had one yesterday but not as concerning as if they're telling you they have a seizure every week also if they say that they had a seizure yesterday then you need to ask them well did you have it looked at have you been to the hospital have you been to the doctor what did they say are you currently taking any medications for that are they looking into it you know things that you do have to know because in some cases if a patient let's say had a a serious seizure yesterday you may not want to see them you may say to them well until you have it under control or until they know the cause I don't feel safe treating you or in some cases it may still be fine if they say to you well the doctor told me that I had a very minor seizure yesterday they're not concerned the doctor said that it was because I got too hot and was exercising too much I don't know that's a horrible example but you get the idea you always have to ask more questions and if you're ever not sure it doesn't hurt to ask the dentist you know say to them my patient had a seizure yesterday the doctor doesn't know why they feel okay today but do you think that I should continue on typically in that case he or she the dentist will say to you to take the blood pressure and then to go from there because if the if the blood pressure is overly high then you may not want to see them anyway because there still could be something happening right but you know even even having that said a seizure isn't as serious as let's say they had a heart attack yesterday you know that's something a lot more serious but still a a seizure isn't normal right it's not normal so you still have to ask further questions um the only time that I'm typically not concerned is that they say well I did have a seizure ten years ago but I haven't had one since if they're not taking anything for it then they are probably going to be okay but it's still a good idea to ask questions another question a lot of patients typically circle yes to if they've had any surgery but then they don't tell you the type of surgery so you do have to ask you know this made me a little bit uncomfortable if you're new at this whole thing but you do have to ask and you know I think it's kind of self-explanatory that if you circle yes to having surgery the patient should know will they need to know what type of surgery you know it could be surgery on their finger it could be surgery on their neck it could be well they had a heart attack and had to have surgery you know you just never know because the patients sometimes don't think that teeth and health go hand in hand and hit so you still have to ask these questions like I had a patient circle yes to that question and when I had said well what type of surgery did you have he said well I had a heart attack last year yet nowhere else in the medical history did it say he had a heart attack so it's a good thing that I did ask the question right because that's pretty serious something you have to know because if they had a heart attack let's say six months ago you cannot see them it has to be at least six months after the heart attack okay because things could be happening in there you know what who knows right so you need to ask these questions another one that I had before was a patient circling yes to having surgery and they had a cancerous tumor removed from their lung I believe but nowhere else on the medical history did it say they had cancer that's pretty serious right so you always have to ask questions another common one is a question about if they have an issue with their thyroid if they circle yes you need to know if it is hyper or hypo you know just things you have to know level thyroxine if I'm saying that right is a common medication for that but typically patients will say to you well I'm taking a medication for my thyroid but I don't know which one so if so if you say well does it have to do with they may say yes that's it or they may say no that's not it you know so then you have to ask them and try to figure out what they're taking um in some extreme cases like if they have no idea then say to them as soon as you get home phone the office and let us know all of the medications because you do have to have that on file you do have to have the full name how how often they take it and the dosage also so there's lots of things that you do have to know um let's see you guys I'm just trying to think of some more common questions so as I said before just typically if the patient answers yes to anything you need to ask more questions let me think I'm currently on holidays at the moment so it's been a while since I went through the medical history so I'm just trying to think what else because in our office we update the medical history every three years and they have to do a new one or I should say they have to do one at every single new patient exam so I'm just sort of going from that in my head thinking of the common questions and the common things that I typically have to ask further another one is that if you ask on the medical history do you have high or low blood pressure and they circle yes you have to know which one so is it the high blood pressure or is it the low blood pressure and you and you also have to ask are you taking any medications for that yes or no if they are the next the next question that you have to ask is when you are taking the metal on the medication what is a normal blood pressure for you because I've had patients say that they're taking a medication for high blood pressure and their normal is 140 over 86 you know that's high but that may be normal and you know a high normal to them okay because if they say well if my blood pressure reaches 155 then I know that I do have to go to the hospital because something is wrong but 145 you know to me is normal because you have to remember that normal is 120 over 80 but if a patient has high blood pressure and is on medication the normal for them made me higher than the average so that's important to know Plus if a patient does have high blood pressure check it at every appointment because you need to make sure that they are okay and don't only check it once check it at least twice because I had a patient um she was a um he was actually the husband of the hygienist at the office his blood pressure was 160 over 80 that's high and he didn't seem concerned he said well that's uh normal for me but that is still high so I said to him well I'll check it again and in a couple minutes so I waited about five minutes and then it was about 148 over 86 I think 87 maybe so that made me happy but it's still high right so if you're not sure check with the dentist and say to them you know their blood pressure was this so I took it five minutes later and then it was this their pulse seems a little bit high too but I think it's because they're nervous you know so think about all of those things plus if the patient has low blood pressure also it doesn't hurt to check it I add them every single appointment because if it's too low then if you sit them back they may say to you I feel kind of dizzy I think my blood pressure is too low right because if a patient has low blood pressure that's not a good thing either because if you sit them up too quickly they will probably say to you like whoa I don't feel so good I'm dizzy I'm gonna pass out so it's so important that if a patient has low blood pressure don't sit them up too quickly and make sure they you know I'm after you sit them up make sure they just sort of take it easy and sit for at least a moment or two because there are a lot of patients out there who will you will sit them up and then they're like oh okay whoa wait a minute just take your time you have a little blood pressure if you get up too quickly you could just kind of pass out right so just take your time because some patients of course are anxious to leave but especially somebody with low blood pressure they need to take their time because if they're laying back for 45 minutes you sit them up slowly that's awesome but then if they start to sit up right away then that's not helping them either right so think about the ones with high blood pressure and low blood pressure also let me think what's another one if the patient circles yes you have a reaction to local anesthetic ask them more questions because sometimes it could be topical it could be local they could have had a reaction when they had their wisdom teeth taken out and they were put to sleep because that's not local that is general anesthetic so that is something different nitrous oxide some patients think that's look that's local anesthetic but it's not right so always ask them questions say well what happened when you had that reaction to local anesthetic and then they may say to you well when they put on the laughing gas I felt a little bit funny well that is not having a reaction right to local anesthetic that is how you're supposed to feel with nitrous oxide but sometimes patients just simply don't know right or they may say to you well when they put me to sleep you know this this and this happened well that's not local anesthetic so always ask the questions I thought of another one if the patient circles the yes to having an allergy ask them questions is it seasonal allergies is it they're allergic to is it they're allergic to bananas you know ask some questions I've had so many people say to me they don't have allergies but then when I asked them do you have many allergies to medications they may say well yeah I'm allergic to that's an allergy but I think they think we're asking them if they have seasonal allergies or food allergies maybe but always ask some questions you know because that's so important because there's a lot of patients out there that that are allergic to so if they ever need antibiotics you can't give them the but if they say that they do have an allergy ask them what happened you know if they say well I took kind of selling when I was a kid and I got a rash you know that is still an allergy but if they said to you well when I had my heart stopped well that's a lot more serious right so you need to make notes of all of these things um okay guys that's kind of all I can think about at the moment I do hope this helped just kind of thinking for a second if there's any other serious questions I'd say those are the most serious and those are the common questions where patients just don't know how to answer them properly so I do hope that that helped to end off just remember that if the patient answers yes to anything on the medical or the health history ask them more questions don't simply say okay and then move on ask them more questions so I do hope this helped and stay tuned for the next video