Antibiotics questionnaire

Patient Information
Full Name
Email
example@example.com
Date of Birth

DayMonthYear
Contact Information

Dental Procedure Information:
1. Which dental procedure are you scheduled for?

Tooth extractionDental implant placementPeriodontal procedures (e.g., surgery, scaling, root planing)Root canal treatmentOther
2. Do you have any symptoms of a current oral infection?

SwellingPainRednessPus

Additional Notes:
Please list any other medical conditions or concerns that you think may be relevant:
Please list all medications you are currently taking, including over-the-counter drugs and supplements.

Medical Practitioner's information:
Primary Care Physician and Contact Information
Do you have a cardiologist?

YesNo
Please provide the following details for your Cardiologist:-
Name
Contact information
Address
Have you consulted with your cardiologist regarding this dental procedure?

YesNo

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 judgment 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.
Should be Empty:

Patient Information

Medical History

Dental Procedure Information:

Additional Notes:

Medical Practitioner's information:

Risk Assessment for Antibiotic Prophylaxis

Instructions for Use: