Clinical examination & record-keeping: Part 2: History taking

Key Points

  • Discusses how information can be gathered from the patient prior to the chairside consultation with the clinician.

  • Provides guidance on collecting dental, medical and socio-behavioural history from patients.

  • Contains a useful quick reference list of recommendations for history taking, specifying whether elements are conditional, basic or aspirational.


This article is the second part of a BDJ series of Practice papers on the subject of clinical examination and related record keeping. The series is taken from the Faculty of General Dental Practice UK (FGDP[UK]) 2016 Good Practice Guidelines book on this topic, edited by A. M. Hadden. This particular article discusses history taking, where information may be gathered prior to the patient seeing the clinician or, in some cases, this may be carried out chairside by the individual. The information gathered can include a medical history, socio-behavioural history, and patient anxiety levels. It is important to note that throughout this article (and the BDJ series and associated FGDP[UK] book), the specific guidelines will be marked as follows: A: Aspirational, B: Basic, C: Conditional. Further information about this guideline notation system is provided in Part 1 of this series (BDJ 2017; 223: 765–768).

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  1. 1

    General Dental Council, Standards, Guidance, Standard 4.1.1, 2013. Available online at (accessed November 2017).

  2. 2

    Scully C, Boyle P . Reliability of a self-administered questionnaire for screening for medical problems in dentistry. Community Dent Oral Epidemiol 1983; 11: 105–108.

    Article  Google Scholar 

  3. 3

    de Jong K J, Abraham-Inpijn L, Vinckier F, Declerck D . The validity of a medical risk-related history for dental patients in Belgium. Int Dent J 1997; 47: 16–20.

    Article  Google Scholar 

  4. 4

    Nikias M K, Sollecito W A, Fink R . An empirical approach to developing multidimensional oral status profiles. J Public Health Dent 1978; 38: 148.

    Article  Google Scholar 

  5. 5

    Burke F J, Wilson N H . Measuring oral health: an historical view and details of a contemporary oral health index (OHX). Int Dent J 1995; 45: 358–370.

    PubMed  Google Scholar 

  6. 6

    Locker D . The burden of oral disorders in a population of older adults. Community Dent Health 1992; 9: 109–124.

    PubMed  Google Scholar 

  7. 7

    Humphris G M, Morrison T, Lindsay S J . The Modified Dental Anxiety Scale: Validation and United Kingdom Norms. Community Dent Health 1995; 12: 143–150.

    PubMed  Google Scholar 

  8. 8

    Green R M, Humphris G M, Lindsay S E, Mellor A C, Millar K, Sidebotham B . Minor psychiatric morbidity, pain and fear in patients in general dental practice. Community Dent Oral Epidemiol 1997; 25: 187–188.

    Article  Google Scholar 

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Correspondence to A. M. Hadden.

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Hadden, A., and the FGDP(UK) Clinical Examination and Record-Keeping Working Group. Clinical examination & record-keeping: Part 2: History taking. Br Dent J 223, 823–825 (2017).

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