Physical Evaluation

By Brian J. Gray, DDS, MAGD, FICOI

That first visit to a dental office is often faced with a degree of anxiety. What will happen at this first visit?

In addition to welcoming the new patient to their dental practice and getting information about their oral health needs, the doctor and his/her staff will need to obtain some very important information from that person regarding their health history in order to make their future dental visits as pleasant and as safe as is possible.

It is important that the patient be honest with their doctor in answering these questions. Though there is usually no direct correlation between an existing medical condition and the dental care they are about to receive, there are specific instances where the planned dental treatment may require modification or even be postponed due to a pre-existing medical problem.

In order to obtain this information, the doctor will do the following:

1. Medical history questionnaire: The medical history questionnaire is a form that usually is filled in by the patient. It will ask questions regarding the status of their past and present health. The patient reads this form carefully and then answers each question to the best of their ability. Most forms will ask for a list of any drugs or medications the patient is currently taking. It is very important that they give a complete list of ALL medicines, including over-the-counter and herbal remedies, as well as any prescription drugs they may be taking.

   In the list of medical problems, the patient should not hesitate to check the appropriate box, yes or no, for each problem listed.

   Any medical information obtained from the patient during this physical evaluation is considered to be confidential.

   The Medical History Questionnaire must be signed by the patient or by a legal guardian, if they are legally a minor.

   It is important for the patient to notify their doctor prior to the start of dental treatment if there is ever any change in their medical condition.

2. Record vital signs: The doctor or a dental auxiliary (dental hygienist or dental assistant) will record blood pressure and take a reading of a patient's heart rate (pulse) and breathing rate. In addition, in some situations, body temperature may be recorded.
3. Dialogue history: The doctor or dental hygienist then will review with the patient all of the findings obtained from the Medical History Questionnaire and the recording of their vital signs. In response to any positive answer (such as diabetes or high blood pressure), additional questions will be asked to determine the significance, if any, of this medical condition to the individual's planned dental treatment.

The goal in obtaining an accurate medical history from the patient is to enable the doctor to make their planned dental treatment as safe and as comfortable for the individual as possible.