Health History

An Updated Multiple Language Health History for Dental Practice

To properly assess a patient, a variety of questions are necessary to evaluate signs and symptoms of medical problems and to find out about diagnosed medical problems and specific medical treatments, including the use of drugs or medications. All of these factors can have a bearing on dental management. Because of the diversity of the population, a variety of languages are spoken in California and the United States. So that dentists can communicate with those diverse groups, a health history form developed at the University of the Pacific School of Dentistry has been translated into 10 languages. The translated forms and the corresponding English form are presented along with an explanation and rationale for their use.

First, do no harm. That is a basic tenet in the delivery of health care. A complete medical history is the required centerpiece of every patient evaluation, ensuring that we do no harm. In dentistry, the medical history has always been considered an integral part of the initial interview process and the ongoing care of a patient. It is designed to identify medical problems or conditions that would put the patient (or the practitioner, in the case of infectious diseases) at an increased risk during dental procedures.

Most dental practices will have a patient complete a health history questionnaire, which makes the process more efficient and ensures that no questions are missed. The validity of the health history questionnaire is well-documented.¹

This questionnaire must be followed up with a verbal interview to ensure that the patient properly understood the questions and to give the clinician an opportunity to ask about any positive responses.

The health history has become increasingly necessary and appropriate because a growing number of patients have ongoing medical problems. An extensive survey of more than 29,000 dental patients in the Netherlands revealed that 1 out of 5 answered "yes" to having a medical problem.² As patients grow older, they have more medical problems, the problems are more severe, and the potential for complications during dental therapy increases.

All patients, even young and apparently healthy ones, require a thorough health history review. The incidence of disease increases with age, however; and statistics clearly indicate that the population as a whole is aging. Medications are allowing medically compromised people to live longer and remain mobile. Patients are also keeping their teeth longer and, therefore, need and desire more dental procedures. All of these factors create a dental, medical, and legal environment that requires a current and thorough medical history.

The Department of Pathology and Medicine and the Department of Diagnosis and Management at the University of the Pacific School of Dentistry have developed a thorough health history questionnaire to evaluate all patients presenting to the school. This questionnaire is up-to-date and conforms to all the legal requirements for a health history (see Health History form). The accompanying health history interview sheet completes the medicolegal requirements for a thorough evaluation and assists the practitioner in ensuring that no medical problems have been overlooked (See Health History Interview Sheet form).

Based on the diverse populations seen at the dental schools in California, as well as in the rest of the United States, the University of the Pacific health history has been translated into several languages. The numbering and sequence of all the questions on all the health histories is exactly the same. This allows the correlation of the health history questions. The questions on one health history form exactly match the same numbered question on the other health history forms. An English practitioner can effectively evaluate a Vietnamese-speaking patient’s medical problems by using the appropriate health history translation and then correlating it to the English version. For that matter, a dentist who speaks primarily Spanish or any of the other included foreign languages, can effectively evaluate an English-speaking patient by correlating the health history forms.

The 1990 Census³ revealed that although English is the official U.S. language, a significant number of people in California primarily speak another language at home. In California, Spanish is the second most common language spoken at home, although other languages are also relatively common (Table 1). The languages selected for interpretation range from those spoken commonly in California (Spanish, Cantonese) to the relatively obscure (Hmong). Although the Hmong speakers do not account for large numbers, relative to the population of California, they make up a significant population group in certain locales and in some individual dental practices. Being capable of communicating with diverse populations is crucial to those patients and those dentists.

The series of dental-related health histories that follow make up the largest collection of correlated health history translations for dental offices in the world. The health history itself and the number of languages into which it has been translated have been updated since its prior publication in the Journal of the California Dental Association in 1993.⁴

A sensitivity to and an appreciation for the diversity found in California and in specific practices ensures a high standard of personalized professional dental care. This respect is an important first step in establishing appropriate patient rapport and optimal working relationships.

Health History Form

The health history form is divided into specific segments designed to elicit different types of information from the patient.

General Questions

Section I is designed to elicit general information about the patient’s health and whether they have seen a physician recently, are currently in pain, or have had any problems with prior dental treatment.

Signs and Symptoms

Section II focuses on various signs and symptoms that are indicative of medical problems. Signs are indications of disease that can be observed by the practitioner, e.g., swollen ankles. Symptoms are problems that, though often indicative of disease, can be experienced only by the patient, e.g., the pain from a toothache.

As can be noted in this section and others, no time frame is given for the problem or complaint. Therefore, the patient may answer "yes" for a sinus problem that had occurred many years ago. This is intentional because judging the relevance of the time frame is the responsibility of the clinician. Pertinent information may be missed if the questions are restricted to problems that have occurred in the past year. A "yes" response may require a medical consult for a definite diagnosis.

Specific Diseases

Section III concentrates on specific diseases that have been previously diagnosed. All of the diseases, signs and symptoms, and other questions on the health history have dental relevance. Again a medical consult may be required depending on the current situation.

Three changes have been made to this section in this revised version of the health history. Asthma has been added to item #35 because of its increased frequency in the population and the potential of a flare-up during dental treatment. Due to the increasing frequency of latex allergies and the prevalence of latex-containing supplies in dentistry, item #38 now asks about latex allergies specifically. Finally, ARC (AIDS-related complex) has been omitted from item #40 because it is a term and concept no longer used in describing HIV-disease.

Treatments

Section IV discusses medical treatments and prosthetic devices, which can have a bearing on dental management. Decisions regarding dental management depend on the patient’s specific situation and the extent of the treatment and/or resultant outcome.

Medications and Drugs

Section V elicits important information on prescription and over-the-counter medications, natural remedies, and any other drugs the patient might be taking. This new health history has incorporated a prompter about natural remedies because the use of these compounds is so widespread. One study found that up to 42 percent of the population has utilized "alternative medicine" therapies at least once in the previous year.⁵ The current medication history is extremely pertinent and documents the extent of any problems identified on other parts of the health history (and at times the existence of problems not identified by the patient). This information can have a bearing on management as well as the potential for adverse drug reactions. The tobacco and alcohol use and history should also be addressed by the dental professional.

Women Only

Section VI elicits specific information relative to women such as pregnancy, nursing, and use of birth control pills.

All Patients

Section VII consists of a catchall question designed to elicit information the patient believes is appropriate to provide but which has not been otherwise queried.

It is then appropriate for the patient to sign and date the health history form. The patient should review the health history at selected intervals and re-sign it after each review thereby documenting that there have been no changes. The frequency of review depends on the practitioner’s preference and the volatility of the patient’s medical status. Most commonly, offices have patients review and update their health histories approximately every six months to one year, usually at their hygiene recall visit. If there have been any health changes, it is appropriate for the clinician to review the pertinent information and re-sign the interview sheet to document the review.

Health History Interview Sheet

The health history interview sheet ensures that any questions answered positively are followed up appropriately and documented. It also provides a location for any significant findings and a description of any dental management considerations. Medicolegally, this also allows a separate area for the dentist’s edits, comments, and notes. The dentist should not alter the patient questionnaire or add notes on that sheet. If the dentist believes an edit on the questionnaire is crucial for clarification, any edit should be dated and initiated by the patient. The most important set of reminders on the interview sheet are the six questions on the right-hand side, which should be asked of the patient even if the patient has already answered them in the negative on the questionnaire. These six areas are extremely important in dentistry, and it is appropriate to ensure that the patient properly understood the intent of the questions. These crucial questions are as follows.

Cardiovascular

Cardiovascular problems make up the bulk of the medical problems that require dental management considerations. One study estimates that approximately 51 percent of those patients with medical complexities have cardiovascular problems, and the incidence of cardiac problems increases rapidly as patients age.² Most specifically, heart problems or heart murmurs should be investigated. Patients may or may not understand the term "cardiovascular," but if they have had a heart problem or murmur, they will recognize that terminology and answer appropriately. Frequently, a patient will answer "no" to "heart murmur" on the questionnaire but acknowledge the diagnosis of such during the interview.

Infectious Diseases

This is designed primarily to define any active infectious problem. Hepatitis is the most common infection with dental implications or complications. Another important infectious disease is advanced HIV infection or AIDS because of concurrent oral problem and systemic changes. Both hepatitis and HIV disease can lead to hematologic changes (e.g., increased bleeding) and problems with healing. Since all patients are treated as though they are infectious (universal precautions), this section is not designed to elicit information that would alter infection control protocols. Infection control protocols should be the same for all patients, except for active tuberculosis patients. This information on infectious diseases may also be important in the management of a parental exposure incident, if one occurs.

Allergy to Medicines

Allergies are always a concern in dentistry because of the variety of medications used. Penicillin and aspirin have relatively high allergic rates; and the responses can be very severe, including life-threatening anaphylactic reactions. A patient should be asked about allergies in general and if they have allergies to antibiotics, pain medications (including aspirins), local anesthetics, or narcotics specifically. (Allergies to medications used in dentistry are extremely rare and often based on a previous anxiety-based adverse response). A patient’s reaction to drugs still needs to be identified even though they may be nonallergic reactions such as side effects, idiosyncratic reactions, and responses to toxicities.

Hematologic

Positive answers relative to prolonged bleeding or bruising may identify a bleeding problem. This problem can occur as a result of many conditions, including the use of medications such as aspirin.

Medications

As on the written health history, the medications a patient is taking reveal extremely important information about his or her medical condition. It documents that the nature of the medical problem is enough to warrant medical treatment. It also provides information for awareness relative to particular side effects, problems with certain medications, and potential for certain drug interactions. Information about over-the-counter, natural, and herbal medications should also be elicited and recorded.

Other Medical Problems Not Asked

In a comfortable one-on-one confidential setting, this catchall question may elicit information about medical problems that may have a bearing on dental therapy. This question may also uncover a variety of anxieties or concerns a patient may have but will not write down. A patient may be more open to discussing such concerns once he or she has established rapport with the practitioner.

Summary

The incidence of medical problems increases as the population ages and more medically compromised people are ambulatory and present for dental care. A patient-generated health history and the doctor-conducted health history interview are the standard of care, a medicolegal requirement, and a crucial aspect of proper dental patient management.

To properly assess a patient, a variety of questions are necessary to evaluate signs and symptoms of medical problems and to find out about diagnosed medical problems and specific medical treatments, including the use of drugs or medications. All of these factors can have a bearing on dental management. Because of the diversity of the population, a variety of languages are spoken in California and the United States. To communicate with those diverse groups, the UOP health history has been translated into 10 languages.

The utilization of a fully interpreted health history ensures that adequate information is elicited from the patient and illustrates the respect and concern a practitioner has for each patient.

Since the questions on the various translated questionnaires all correspond numerically with each other and with the questions in English, a positive response in a language not spoken by the clinician can be correctly interpreted and appropriate interview questions completed. Of course, if adequate follow-up cannot be conducted because of a language barrier, an interpreter can be requested to ensure that no medical problems arise during dental therapy because of confusion about the medical history.

Acknowledgments

The authors would like to acknowledge the contributions of the faculty the Department of Pathology and Medicine and the Department of Oral Diagnosis and Patient Management at the University of the Pacific Dental School. They have put many hours into developing the health history and perfecting it over the past several years. Their academic input has been crucial to the quality of the health history.

The authors would also like to acknowledge the following people for their efforts toward translating the English version of the health history into their native languages. Their contributions, time, and effort were invaluable and are much appreciated.

* Chinese -- Dr. Hai Loo, Dr. Stephen Yao, Dr. Polly Chan

* Farsi -- Dr. Katayoun Alaei, Dr. Soheil Goel, Dr. Faroud Hakim

* Hmong -- Mr. Hai Her, Ms. Mao Her (dental student)

* Korean -- Dr. Myoung Lee, Ms. SuJin Mayeda

* Laotian -- Mr. Nai Her

* Russian -- Dr. Leonid Tolstunov, Ms. Yelena Ostrovsky (dental student)

* Spanish -- Dr. Guillermo Canjura, Garrett Guess (dental student), Dr. Noelle Fannuci, Dr. Oriol Llena

* Tagalog -- Dr. Bert Masangkay

* Thai -- Dr. Noellette Falkow, Dr. Warasiri Pitakanonda

* Vietnamese -- Dr. Lich Khoung, Ms. Chan Long Nguyen (dental student)

Transcend of Davis, Calif., typeset and certified the translations.

Permission for the duplication and use of these health histories is given to private practicing dentists and public and private dental clinics. The use, duplication, or resale of the health history and translations for or by commercial interests is not authorized. Requests for commercial use must be directed to the authors. Arrangements for translations into other languages can be made by contacting the authors.

Authors

Peter L. Jacobsen, PhD, DDS, is the director of oral medicine at the University of the Pacific School of Dentistry.

Richard Fredekind, DMD, MA, is an associate professor in the Department of Diagnosis and Management and a group practice administrator at UOP School of Dentistry.

Alan W. Budenz, MS, DDS, is an assistant professor of anatomy and chair of the Department of Diagnosis and Management at the UOP School of Dentistry.

William M. Carpenter, DDS, MS, is professor and chairman in the Department of Pathology and Medicine at the UOP School of Dentistry.

References

1. De Jong KJM, Borgmeijer-Hoelen A, and Abraham-Inpijn L, Validity of a risk related patient administered medical questionnaire for dental patients. Oral Surg, Oral Med, Oral Path 72:527-33, 1991.

2. Smeets EC, De Jong KJM, and Abraham-Inpijn L, Detecting the medically compromised patient in dentistry by means of the medical risk related history. Prevent Med 27:530-5, 1998.

3. Census of Population and Housing, 1990, Summary Tape File 3, CA. Population: Language Spoken at Home/prepared by the Bureau of the Census. The Bureau State Census Data Center, Washington, 1991.

4. Jacobsen PL and Fredekind R, A multiple language health history for dental practice. J Cal Dent Assoc 21(5):25-7, 1993.

5. Eisenberg DM, Davis RB, et al, Trends in alternative medicine use in the United States, 1990-1997. J Am Med Assoc 280:1569-75, 1998.

To request a printed copy of this article, please contact/ Peter L. Jacobsen, PhD, DDS, UOP School of Dentistry, 2155 Webster St., San Francisco, CA 94115 or at pjacobse@uop.edu.

Table 1