CLINICAL DENTISTRY GUIDELINES
Clinical Criteria Guidelines
Page 4
NEW PATIENT INFORMATION
A. Registration information should include:
1. Name, sex, birth date, address and telephone number, cell phone number, e-mail address, name of employer,
work address and telephone number, language of preference.
2. Name and telephone number of person(s) to contact in an emergency.
3. For minors, name of parent(s) or guardian(s) and telephone numbers, if different from above.
4. Pertinent information relative to the patient’s chief complaint and dental history, including any problems or
complications with previous dental treatment, previous dentist/dental clinic and date of last dental examination.
5. Medical History - There should be a detailed medical history form comprised of questions which require a “Yes”
or “No” response, including:
a. Patient’s current health status
b. Name and telephone number of physician and date of last visit
c. History of hospitalizations and/or surgeries
d. Current medications, including dosages and indications
e. History of drug and medication use (including Fen-Phen/Redux and bisphosphonates)
f. Allergies and sensitivity to medications (including antibiotics) or materials (including latex)
g. Adverse reaction to local anesthetics
h. History of diseases or conditions:
i. Cardio-vascular disease, including history of abnormal (high or low) blood pressure, heart attack,
stroke, history of rheumatic fever or heart murmur, existence of pacemakers, valve replacements
and/or stents and bleeding problems, etc.
ii. Pulmonary disorders including COPD, tuberculosis, asthma and emphysema
iii. Nervous disorders, including psychiatric treatment
iv. Diabetes, endocrine disorders, and thyroid abnormalities
v. Liver or kidney disease, including hepatitis and kidney dialysis
vi. Sexually transmitted diseases
vii. Disorders of the immune system, including HIV status/AIDS
viii. Other viral diseases
ix. Musculoskeletal system, including prosthetic joints and when they were placed
x. History of cancer, including radiation or chemotherapy
6. Pregnancy
a. Document the name of the patient’s obstetrician and estimated due date.
b. Follow current guidelines in the ADA publication, Women’s Oral Health Issues.
7. The medical history form must be signed and dated by the patient or patient’s parent or guardian.
8. Dentist’s notes following up patient comments, significant medical issues and/or consultation with a physician
should be documented on the medical history form or in the progress notes.
9. Medical alerts for significant medical conditions must be uniform and conspicuously located on the monitor for
paperless records or on a portion of the chart used and visible during treatment and should reflect current
conditions.
10. The dentist must sign and date all baseline medical histories after review with the patient. If electronic dental
records are used, indication in the progress notes that the medical history was reviewed is acceptable.
11. The medical history should be updated at appropriate intervals, dictated by the patient’s history and risk factors,
and must be documented at least annually and signed by the patient and dentist.
CLINICAL ORAL EVALUATIONS
A. Periodic oral evaluations (Code D0120) of an established patient may only be provided for a patient of record who
has had a prior comprehensive examination. Periodontal evaluations and oral cancer screenings should be updated
at appropriate intervals, dictated by the patient’s history and risk factors, and should be done at least annually.