SupportPatient Management

Medical History

7 min read
Last updated: February 18, 2026

Medical History

Comprehensive medical history documentation is critical for safe dental treatment. MyDentalPractice provides structured forms to capture, update, and review patient medical data.

Accessing Medical History

  • Open a patient record from Patients → All Patients
  • Click the Medical History tab in the patient profile
  • You will see sections for general health, dental history, and clinical notes
  • General Health Section

    Allergies

    Click + Add Allergy to record each known allergy:

  • Allergen — The substance (e.g., Penicillin, Latex, Lidocaine)
  • Severity — Mild, Moderate, or Severe
  • Reaction Type — Rash, Swelling, Anaphylaxis, etc.
  • Notes — Additional details about the reaction
  • Allergies marked as Severe are highlighted in red across the application — on the appointment card, in the treatment view, and on prescriptions.

    Medical Conditions

    Toggle conditions from the pre-built checklist:

  • Diabetes (Type 1 or Type 2)
  • Hypertension
  • Heart disease
  • Asthma
  • Bleeding disorders
  • Hepatitis (A, B, or C)
  • HIV/AIDS
  • Epilepsy
  • Pregnancy (current)
  • Other — free-text field for conditions not listed
  • Current Medications

    For each medication, record:

  • Medication Name — Brand or generic name
  • Dosage — Amount and frequency (e.g., "500mg twice daily")
  • Prescribing Doctor — Who prescribed it
  • Start Date — When the patient started taking it
  • Dental History Section

    Previous Treatments

    Record the patient's prior dental work:

  • Fillings (amalgam, composite, ceramic)
  • Extractions — which teeth and approximate dates
  • Root canal treatments
  • Crowns, bridges, or dentures
  • Orthodontic treatment history
  • Implants
  • Dental Habits

    Document relevant habits:

  • Brushing frequency (once, twice, or more daily)
  • Flossing frequency
  • Tobacco use (smoking, chewing)
  • Alcohol consumption
  • Bruxism (teeth grinding)
  • Thumb sucking (pediatric patients)
  • Clinical Notes

    Each visit generates a clinical note. To add a note:

  • Open the patient's Medical History tab
  • Click + Add Clinical Note
  • Select the date and the treating dentist
  • Enter findings, diagnosis, and treatment performed
  • Click Save Note
  • Clinical notes are displayed in reverse chronological order, giving the most recent information first.

    MyDentalPractice includes a digital consent form template. Under Settings → Templates, you can customize the medical history consent form that patients sign during registration.

    Exporting Medical History

    To export a patient's complete medical history:

  • Open the patient profile
  • Click the Export button (top right)
  • Select Medical History PDF
  • The system generates a formatted PDF with all recorded data
  • This is useful for referrals to specialists or when a patient requests their records.

    For uploading supporting documents like X-rays, see Document Upload.

    Still need help?

    Our support team is available Monday-Friday, 9am-6pm WAT.