Definition of medical history collection: through doctor's consultation, understand the reasons and requirements of patients seeking medical treatment, and obtain the information of patients' systematic medical history and oral medical history. This is a medical history collection.
Therefore, no matter what symptoms we encounter in the exam, the current medical history and related medical history are what we need to focus on.
Outpatient medical records include: comprehensive requirements
Name, sex, age, marriage, occupation, place of birth, location of complaint, time, nature and degree, current medical history, relevant medical history, allergic history and physical examination.
X-ray, cold and hot diagnosis and other laboratory tests, preliminary diagnosis and treatment advice, signed by the doctor.
Especially in relation to the mouth and teeth:
Current medical history and related medical history:
The number of teeth (whether the patient can locate), the nature of pain, the inducement, what situation is relieved, the difference between day and night, local or radiation pain, whether it has been treated, whether there is systemic disease, and whether there is a history of injury;
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