CDAMP Take Preliminary Medical History (click here to download)


CDAMP MODULE V SKILL SHEET (Complete this skill with 4 patients)

(please use 4 separate sheets, one for each skill)

EVALUATION: Take Preliminary Medical Histories

STUDENT NAME _________________________________ID # _________

DATE ________________________ PATIENT’S INITIALS _________

Materials: 0 – 10 points

The following armamentarium is present:

___ Medical-dental health history form on clip board, black ink pen,
red ink pen, patient’s chart, “ALERT” sticker

Steps: 0 –10 points each (N/A if not applicable)

___ 1. Instructs patient (or parent/guardian if patient is not of legal age) to
complete form, sign, and date with a black ink pen
___ 2. Reviews form with patient and assists with any unanswered or
unclear items on form
___ 3. Circles in red any medications taken, health conditions listed,
drug sensitivities, allergic reactions, or premedication requirements,
which would determine patient’s treatment plan
___ 4. Relates pertinent information to the dentist
___ 5. Transfers circled information to patient’s chart in “medical alert”
___ 6. Affixes “ALERT” sticker on inside cover of patient’s chart to insure
___ 7. Asks returning patient to update their medical history at each visit
___ 8. Has patient write “no change” if there is no change in their health
___ 9. Has patient sign and date each update


Preceptor declares skill was successfully completed. (75% of total possible points)

PRECEPTOR’S SIGNATURE _________________________________________

STUDENT’S SIGNATURE ___________________________________________