Medical history form for dentist and orthodontist (incl. free template!)
Probably the most important instrument in diagnostics is still the patient's medical history - this also applies to dental and orthodontic practices! Read here what you should pay attention to and use the free anamnesis sheet for download!
All answers to the medical history form for dentists at a glance:
In der Regel sollte die Anamnese bei Neupatienten durchgeführt und danach etwa einmal jährlich wiederholt werden. Teilweise raten Ärzte sogar dazu, die Anamnese bei jeder Behandlung neu durchzuführen. Dafür gibt es keine genauen gesetzlichen Vorgaben. Im BGB § 630f ist von einem „unmittelbaren zeitlichen Zusammenhang mit der Behandlung“ die Rede, ohne dass dieser Zeitraum genauer definiert ist.
Ja, die Anamnese ist Pflicht für den Zahnarzt – nicht aber für den Patienten. Dieser hat das Recht, die Auskunft zu verweigern. Jedoch können auch Sie als Zahnarzt in diesem Fall die Behandlung verweigern, wenn Sie die Auskünfte des Patienten für unerlässlich für die Behandlung halten.
Der Anamnesebogen und weitere im Zusammenhang mit der Behandlung entstandene Dokumente sollten mindestens zehn Jahre lang aufbewahrt werden. In einzelnen Fällen kann es sinnvoll sind, die Dokumente bis zu 30 Jahre aufzuheben. Denn erst danach sind etwaige Haftungsansprüche des Patienten erloschen.
The medical history is one of the most important tools for dentists and orthodontists to detect diseases and identify risk factors at an early stage. But what exactly should you pay attention to when creating or revising your case history questions?
What should I bear in mind when filling out the dental history form?
When preparing the medical history form, it is important to ask questions not only about the patient's oral health, but also about the patient's general medical condition.
The indication of a heart condition or diabetes can also be important for you! For example, the oral mucosa of a diabetic is more sensitive than usual and tends to become inflamed. With this knowledge in mind, you as a dentist or orthodontist can optimally tailor the treatment to your patient.
These diseases and treatments, for example, are often asked for in anamnesis forms from dentists:
- Past heart surgeries
- Diabetes
- Blood clotting disorders
- HIV
- Hepatitis
- Diseases affecting the cardiovascular system
- Asthma
- Epilepsy
- Drug intolerances
- Allergies
In addition, it may be important to learn about the circumstances in which your patient lives. For example, stress and sleep disorders can be triggers of teeth grinding.
Written medical history
Normally, this data is requested in the classic way using a paper questionnaire or directly online. It is important to include clear information on medical confidentiality on the written questionnaire. It can also be helpful to have medical history forms available in several languages.
Tip: You can also use Nelly to take the case history, saving time and resources. The special feature here is that the questions are automatically translated into the patient's language. Paper anamnesis sheets in different languages are now a thing of the past!
Test the digital medical history form for dentists with Nelly now!
Oral history
In addition to the written case history, you should ask some additional oral questions. In the best case, ask open-ended questions such as "What brings you to me?" Avoid questions that the patient can only answer "yes" or "no." This approach is the best strategy to obtain all relevant medical data and improves doctor-patient communication.
Anamnesis via gaze diagnostics
Do not rely only on what the patient tells you. You should also use your medical intuition to identify any illnesses simply by observing the patient. For example, a cough may indicate asthma, an infection or an allergy. This in turn allows you to draw conclusions that could be important for your subsequent treatment!
Medical History Sheet Dentist Template Free
Despite all these tips, the initial conception or revision of the questionnaire can be difficult. That is why we have created this medical history questionnaire for dentists , which asks for all the important details without being overloaded with unnecessary questions.
Medical History Orthodontics Template Free
In the case of orthodontists, there are some special features to note within the medical history forms. For example, it is usually asked whether the patient has already undergone orthodontic treatment or whether X-rays of the jaw have been taken recently. We have taken these special questions for orthodontists into account for you in this orthodontic template.
Note: Both anamnesis forms are actually in use in dental and orthodontic practices - and therefore more "tried and tested" than the samples of the dental association!
What privacy rules apply to the medical history form?
The data collected during anamnesis are very sensitive and must of course be treated confidentially. As health data, they are subject to special data protection. No wonder, because: Especially health insurance companies and pharmaceutical companies are interested in this data, which of course must not be disclosed to third parties.
Caution: In fact, the violation of medical confidentiality under Section 203 of the Criminal Code can be punished by a fine or even imprisonment for up to one year.
As a general rule, only data that is really necessary for the diagnosis or treatment of the patient may be requested. For example, a query about a patient's profession or hobbies is only permissible if this information could actually influence the treatment.
Retention periods
In principle, case history sheets must be retained by dentists and orthodontists for ten years after completion of treatment. These are minimum retention periods. In some cases, it is even advisable to keep the documents for 30 years. After this period, any liability claims by the patient become time-barred.
Important: If you digitize the medical history sheets, you should always keep the original on paper. If in doubt, no one can later determine whether the scanned document really corresponds to the original.
Digital anamnesis at the dentist with Nelly
It is better if you have the anamnesis done online. This is very easy with the Nelly software. Patients can use a QR code to take their medical history quickly and easily on their own smartphone. With a link on your website, you can even do this from home! We will advise you on your individual case free of charge and without obligation.
The personal designations used in this article always refer equally to all persons. For the sake of better readability, we do not use the same name twice or in the opposite gender.
The medical history is one of the most important tools for dentists and orthodontists to detect diseases and identify risk factors at an early stage. But what exactly should you pay attention to when creating or revising your case history questions?
What should I bear in mind when filling out the dental history form?
When preparing the medical history form, it is important to ask questions not only about the patient's oral health, but also about the patient's general medical condition.
The indication of a heart condition or diabetes can also be important for you! For example, the oral mucosa of a diabetic is more sensitive than usual and tends to become inflamed. With this knowledge in mind, you as a dentist or orthodontist can optimally tailor the treatment to your patient.
These diseases and treatments, for example, are often asked for in anamnesis forms from dentists:
- Past heart surgeries
- Diabetes
- Blood clotting disorders
- HIV
- Hepatitis
- Diseases affecting the cardiovascular system
- Asthma
- Epilepsy
- Drug intolerances
- Allergies
In addition, it may be important to learn about the circumstances in which your patient lives. For example, stress and sleep disorders can be triggers of teeth grinding.
Written medical history
Normally, this data is requested in the classic way using a paper questionnaire or directly online. It is important to include clear information on medical confidentiality on the written questionnaire. It can also be helpful to have medical history forms available in several languages.
Tip: You can also use Nelly to take the case history, saving time and resources. The special feature here is that the questions are automatically translated into the patient's language. Paper anamnesis sheets in different languages are now a thing of the past!
Test the digital medical history form for dentists with Nelly now!
Oral history
In addition to the written case history, you should ask some additional oral questions. In the best case, ask open-ended questions such as "What brings you to me?" Avoid questions that the patient can only answer "yes" or "no." This approach is the best strategy to obtain all relevant medical data and improves doctor-patient communication.
Anamnesis via gaze diagnostics
Do not rely only on what the patient tells you. You should also use your medical intuition to identify any illnesses simply by observing the patient. For example, a cough may indicate asthma, an infection or an allergy. This in turn allows you to draw conclusions that could be important for your subsequent treatment!
Medical History Sheet Dentist Template Free
Despite all these tips, the initial conception or revision of the questionnaire can be difficult. That is why we have created this medical history questionnaire for dentists , which asks for all the important details without being overloaded with unnecessary questions.
Medical History Orthodontics Template Free
In the case of orthodontists, there are some special features to note within the medical history forms. For example, it is usually asked whether the patient has already undergone orthodontic treatment or whether X-rays of the jaw have been taken recently. We have taken these special questions for orthodontists into account for you in this orthodontic template.
Note: Both anamnesis forms are actually in use in dental and orthodontic practices - and therefore more "tried and tested" than the samples of the dental association!
What privacy rules apply to the medical history form?
The data collected during anamnesis are very sensitive and must of course be treated confidentially. As health data, they are subject to special data protection. No wonder, because: Especially health insurance companies and pharmaceutical companies are interested in this data, which of course must not be disclosed to third parties.
Caution: In fact, the violation of medical confidentiality under Section 203 of the Criminal Code can be punished by a fine or even imprisonment for up to one year.
As a general rule, only data that is really necessary for the diagnosis or treatment of the patient may be requested. For example, a query about a patient's profession or hobbies is only permissible if this information could actually influence the treatment.
Retention periods
In principle, case history sheets must be retained by dentists and orthodontists for ten years after completion of treatment. These are minimum retention periods. In some cases, it is even advisable to keep the documents for 30 years. After this period, any liability claims by the patient become time-barred.
Important: If you digitize the medical history sheets, you should always keep the original on paper. If in doubt, no one can later determine whether the scanned document really corresponds to the original.
Digital anamnesis at the dentist with Nelly
It is better if you have the anamnesis done online. This is very easy with the Nelly software. Patients can use a QR code to take their medical history quickly and easily on their own smartphone. With a link on your website, you can even do this from home! We will advise you on your individual case free of charge and without obligation.
The personal designations used in this article always refer equally to all persons. For the sake of better readability, we do not use the same name twice or in the opposite gender.
Melanie Schröder
Author
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