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Accurate medical and dental history is critical for patient safety. A documented allergy can prevent a dangerous prescription. A record of past dental work shapes the treatment plan. We give your team structured fields for the information that matters most, while keeping everything encrypted and audit-logged for HIPAA compliance.

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Who can update medical history

Doctors & Admins can update medical and dental history from the clinic side. Patients can also self-update their own medical history through the patient portal.
Regardless of who makes the change, every update is logged in the patient’s activity timeline. The log records that a field changed and who changed it, but not the clinical content itself — this approach satisfies HIPAA audit requirements without exposing sensitive data in activity logs.

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Medical history fields

Medical history captures the general health context your clinical team needs before any procedure.

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Allergies

Recorded as a list of individual allergy entries. Each allergy is stored separately so the system can display them as visual chips on the appointment detail page — red-colored for immediate visibility.
Always verify allergies verbally at the start of each visit. Patients may develop new allergies between appointments that have not yet been recorded.

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Current medications

A list of medications the patient is currently taking. These appear as orange chips on appointment screens so the treating doctor can check for drug interactions before prescribing.

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Past medical conditions

A list of prior conditions the patient has experienced, such as heart disease, diabetes, hypertension, or surgical history. Even resolved conditions can affect dental treatment planning.

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Family medical history

A free-text field for documenting hereditary conditions or family health patterns relevant to the patient’s care. This is especially useful for conditions with genetic components that may influence treatment decisions.

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Lifestyle factors

Smoking status

Tracked as one of three values: Never, Former, or Current. Smoking significantly affects oral health, healing time, and implant success rates.

Alcohol consumption

Documented to help assess overall health risk and potential interactions with medications or anesthesia.

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Blood type

Recorded for emergency reference. While dental procedures rarely require this information, having it on file can be valuable in urgent situations.

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Dental history fields

Dental history captures the patient’s oral health background and habits, helping your team tailor both treatment and preventive guidance.

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Chief complaint

The primary reason the patient is seeking care. This field is typically updated at each visit to reflect the patient’s current concern.

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Previous dental work

A record of past procedures — fillings, crowns, extractions, implants, and other treatments performed at other clinics or before the patient joined yours.

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Clinical indicators

Gum disease history

A yes/no field indicating whether the patient has a history of periodontal disease. This flags the need for closer monitoring during routine visits.

Orthodontic treatment

A yes/no field indicating past or current orthodontic work. Relevant for treatment planning and understanding current tooth positioning.

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Dental anxiety level

A scale from 1 to 10 that helps your team calibrate their approach. Patients with higher anxiety scores may benefit from additional communication, sedation options, or longer appointment slots.
For patients scoring 7 or above on the anxiety scale, consider scheduling them during quieter clinic hours and allowing extra time for the appointment. A note in the appointment record helps the treating doctor prepare.

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Oral hygiene habits

Two fields track the patient’s daily routine:
  • Brushing frequency — How often the patient brushes per day
  • Flossing frequency — How often the patient flosses
These values help your hygienists and doctors deliver targeted preventive advice.

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Last dental visit date

The date of the patient’s most recent dental visit, whether at your clinic or elsewhere. A long gap may indicate higher risk for undetected issues and can inform the scope of examination.

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Patient self-service updates

When patients have portal access, they can update their own medical history before visiting your clinic. This is particularly useful for:
  • New patients completing intake before their first appointment
  • Existing patients reporting new allergies or medication changes
  • Annual health updates between routine visits
Patient-submitted updates appear in the same record as clinician entries. All changes — regardless of source — are tracked in the activity timeline with the identity of who made the update.

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Reviewing medical history before appointments

Medical history is surfaced in multiple places throughout the platform to ensure doctors always have the context they need:
  • Appointment detail header — Allergy and medication chips appear in the persistent header, visible at all times during a visit.
  • Appointment detail right rail — The Medical Issues card shows allergies and medications in a more detailed format.
  • AI Patient Brief — The AI-generated summary on the patient profile incorporates key medical history elements.
Encourage your team to review the medical history before every appointment, even for returning patients. Medical conditions and medications can change between visits, and catching those changes early prevents complications.

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Data security

All medical history data is encrypted at rest. This means the information is protected even in the unlikely event of unauthorized access to the underlying storage. Combined with the audit logging described above, The platform provides layered protection for your patients’ most sensitive information.
The timeline records the date, time, and user who made each change, along with which field was modified. The actual clinical content (for example, the specific allergy added) is not written to the activity log. This protects patient data while still providing a complete audit trail.
No. The activity timeline is only visible to clinic staff. Patients can view and edit their own medical history through the portal, but they do not have access to the internal audit log.
Each update is recorded as a separate event. The most recent change takes effect. If conflicting information is entered, the activity timeline shows the sequence of changes so your team can resolve discrepancies.