History taking is very important for all doctor and dentist. Therefore, all doctor and dentist must spend 5-10mins for taking history from patients because it can make doctor's or dentist's treatment efficiency and potentially. In history-taking, there are 5 vital elements. They are : - Date collection and chief complaint. - Present History - Past History - Personal History - Family History. In those slides, also include the behaviour of doctor or dentist. During interview, Dentist should be : introduce yourself and asking some normal questions => patient feel comfortable for moving forward. always listen carefully. keep your appearance neat and clean => gain trust. show courteous, respectful and confidential always be friendly and interest in patients’ problems. keep eye contact.

1. History-taking
By : Sreng POUV
University Health of Science

2. Content
1. Introduction
2. Element of History-taking
• Date collection + Chief complaint
• Present history
• Past history
• Personal history
• Family history
3. Conclusion

3. Introduction
• Before treated a patient, there are 4 steps to do first :
History-taking, Examination, Diagnostic, and
Treatment plans.
• The first step, history-taking, is the most important
task in diagnostic because it can give the accurate
information that involve with chief complain and also
enhance relationship between doctor and patients.
• History-taking, patient interview, is receiving patient’s
information by asking open or close question.

4. • During interview, Dentist should be :
- introduce yourself and asking some normal questions
=> patient feel comfortable for moving forward.
- always listen carefully.
- keep your appearance neat and clean => gain trust.
- show courteous, respectful and confidential
- always be friendly and interest in patients’ problems.
- keep eye contact.

5. Element of History-taking
• To get an accurate information, we need to take
several type of informations. They are:
- Date collection and chief complaint
- Present history
- Past history
- Personal history
- Family history

6. Data Collection
• Date collection is normal questions that we ask to
patient such as :
Name Sex
Date of Birth Nationality
Religion Phone number *
Address Marital statue
Occupation
• Chief Complaint is the own word of patient that tell
doctor and it is the cause lead patients come to clinic.

7. Present History
1. When did the patient’s problem(s) begin?
2. Where did the problem(s) begin?
3. What kinds of symptoms did the patient experience?
4. Has the patient had any treatment for the problem(s)?
5. Has the treatment had any positive or negative effect on
the patient’s condition?
6. Has the patient’s lifestyle been affected by the
problem(s)?

8. Past History
• Past history is a past treatment of medical or dental treatment. We
need to take it accurately, concisely, and systemically. It is best to
access the disease state of patients by alphabetical order.
Anemia Bleeding Disorder
Cardiorespiratory Disorders Drugs/Medications
Endocrine Disorders
Fits or Faints ( different kinds of
seizures )
Gastrointestinal Disorders ( Oral
Ulcerations )
Hospital Admissions
Immunological Diseases
Infectious Diseases ( Hepatitis, HIV
….)

9. Jaundice or Liver Disese Kidney Disorders
Likelihood of Pregnancy Musculoskeletal Disorders
Neurological Disorders
Obstetric and Gynecological
disorders
Psychiatric Disease Radiation Therapy
Skin Disorders tetanus
Violence Wounds

10. Personal History
• In this part of the history, we ask about lifestyle,
occupation, habit.
- Do you use any drug? birth control ?
- What is your occupation? what do you do for
relaxation, recreation, and so on?
- Do you like to drink coffee or tea ? using
cigarette ? if yes, how much ?

12. Family History
• We should ask more
information about his/her
family health condition,
especially, Coronary
artery disease (CAD),
Heart disease, Diabetes
mellitus (DM),
Hypertension (Htn),
Stroke (CVA), Asthma,
Allergies, Arthritis,
Anemia, Cancer, Kidney
disease, or Psychiatric
illness.

13. Conclusion
• As we are dentist, we should spend 5-10min for
taking informations from patients because it can
helps us and also increases our work potential.

14. Reference
• Dentist’s Guide to
Medical Conditions,
Medications &
Complications.