Women'S Interagency Hiv Study Oral Protocol Medical Evaluation Form Page 2
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1
2
3WIHS ID #
QUESTIONNAIRE
1.
Does the participant have a history of any of the following medical conditions requiring antibiotic
prophylaxis for dental treatment:
DON'T
YES
NO
KNOW
a.
Artificial heart valves? ..............................
1
2
<-8>
b.
Surgically constructed heart-lung
artificial channel or passage? ....................
1
2
<-8>
c.
Heart malformations since birth? ..............
1
2
<-8>
d.
Rheumatic or heart valve disease? ............
1
2
<-8>
e.
Enlarged heart? ..........................................
1
2
<-8>
f.
Mitral valve prolapse (MVP)with a
leaky valve? ...............................................
1
2
<-8>
g.
Heart valve surgery? ..................................
1
2
<-8>
h.
Existing catheter in your bloodstream? .....
1
2
<-8>
i.
Previous infective endocarditis? ................
1
2
<-8>
j.
Localized narrowing of the heart valve
1
2
<-8>
since birth? ................................................
k.
Kidney dialysis with an A-V shunt? ..........
1
2
<-8>
2.
Are prophylactic antibiotics indicated?
YES ............................................... 1
NO ................................................. 2
(5)
3.
Is participant currently on an antibiotic regimen equivalent to that required for dental prophylaxis?
YES ............................................... 1
(5)
NO ................................................. 2
WIHS Form: OP1 - Oral Protocol Medical Evaluation - 10/01/98a
Page 2 of 3
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