Of course if you haven't seen your patient in months or years, you are obligated to update your medical history in detail. The amount of detail and the forms vary, but the responsibility is yours. Obtain an initial dental history on your patient the first time you see them, especially if their presenting problem is dental. Update this history according to your needs and your specific type of practice. In the clinics at VCU School of Dentistry, specific forms for updating the medical and dental history are available.
Physical examination confirms the patient's complaint.
Nine months ago she was diagnosed as bipolar. She has been taking Zoloft for about 9 months. This example illustrates quite simply what you do with data from medical and dental histories. You make connections. You note they listed no illnesses for which they were being treated.