• Patient Information

  • Date of Birth
     - -

  • Medical History

  • 1.   Do you have any of the following heart conditions?
  • 2. Have you had a heart transplant that developed a heart valve problem?
  • 3. Do you have a history of the following?
  • 4. Do you have any immunocompromising conditions, such as:
  • 5. Do you have a history of:
  • 6. Do you have any allergies to antibiotics?

  • Dental Procedure Information:

  • 1. Which dental procedure are you scheduled for?
  • 2. Do you have any symptoms of a current oral infection?

  • Additional Notes:

  • Medical Practitioner's information:

  • Do you have a cardiologist?

  • Please provide the following details for your Cardiologist:-

     

  • Have you consulted with your cardiologist regarding this dental procedure?

  • Risk Assessment for Antibiotic Prophylaxis

  • According to the American Heart Association (AHA) guidelines, antibiotic prophylaxis is recommended for patients with the following conditions undergoing dental procedures that involve manipulation of gingival tissue, periapical region of teeth, or perforation of oral mucosa:

    1. High-Risk Patients:

    • Patients with prosthetic cardiac valves or prosthetic material used for cardiac 
       valve repair
    • Patients with a history of infective endocarditis
    • Patients with certain congenital heart conditions, including:

    • Unrepaired cyanotic congenital heart disease, including those with
       palliative shunts and conduits
    • Completely repaired congenital heart defect with prosthetic material or
       device, during the first six months after the procedure
    • Repaired congenital heart disease with residual defects at the site or
       adjacent to the site of a prosthetic patch or prosthetic device

    • Patients with cardiac transplant who develop cardiac valvulopathy

    2. Moderate-Risk Patients (typically do not require prophylaxis, but
        individual clinical j    udgment is advised):

    • Patients with other congenital heart defects not listed above
    • Patients with acquired valvular dysfunction (e.g., rheumatic heart disease)
    • Patients with hypertrophic cardiomyopathy
    • Patients with mitral valve prolapse with regurgitation

    3. Procedure Risk:

    • Antibiotic prophylaxis is generally recommended for dental procedures that involve:

    • Tooth extractions
    • Periodontal procedures including surgery, scaling, and root planing
    • Dental implant placement and reimplantation of avulsed teeth
    • Root canal instrumentation or surgery beyond the apex
    • Initial placement of orthodontic bands (not brackets)
    • Intraligamentary local anesthetic injections
    • Prophylactic cleaning of teeth or implants where bleeding is anticipated

  • Instructions for Use:

  • • Patient: Please complete this questionnaire as accurately as possible. Provide any
                    additional details where necessary.
    • Dentist/Healthcare Provider: Review the completed questionnaire. Consider
                    the patient's medical history, current health status, and the nature of
                    the planned dental procedure to determine if antibiotic prophylaxis is
                    warranted.

    Guidelines for Antibiotic Prophylaxis:

    • Indicated: Patients with specific heart conditions (listed under high-risk),
                   immunocompromised states, or recent joint replacements undergoing
                   high-risk dental procedures.
    • Not Indicated: Generally healthy patients without the listed conditions or
                  undergoing low-risk dental procedures.

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