Medical history (anamnesis): what it is and why HOF requires it

The medical history, or anamnesis, is the structured interview with the patient to gather their health history before any course of action. The term comes from Greek and means "to bring back to memory." In orofacial harmonization, it is the basis for indicating, contraindicating or postponing a procedure, and the first entry in the patient record.

What does the medical history usually gather?

• Main concern and the patient's expectation, in their own words.
• Current and past illnesses, such as autoimmune, cardiovascular and clotting disorders.
• Medications and supplements in use, including anticoagulants and anti-inflammatories.
• Allergies, including to local anesthetics and to components of the products.
• Pregnancy and breastfeeding.
• Previous aesthetic procedures: product, area, date and any complications.
• History of herpes, skin infections and healing.
• Recent or planned dental procedures.

Why is it so important?

It identifies contraindications and risks before the needle. Knowing there is a permanent filler in an area, for example, changes the plan. Knowing about allergies changes the choice of anesthetic. And understanding the expectation avoids recommending something that will not satisfy the patient.

The medical history also protects the professional: it documents what was asked and answered, and supports informed consent. Because it contains health data, which is sensitive data, its storage follows the LGPD (Brazil's data protection law).

For the practical side, see also the first consultation script. Form templates vary according to the rules of each professional council in Brazil.

Also known as: medical history form, clinical history.