Women'S Interagency Hiv Study Oral Protocol Medical Evaluation Form Page 3
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1
2
3WIHS ID #
4.
a.
Are prophylactic antibiotics being administered specifically for this oral examination?
YES ............................................... 1
(4b)
NO ................................................. 2
____________________________
(5)
SPECIFY REASON
b.
What is being administered?
YES
NO
i.
Amoxicillin 2.0g orally one hour before procedure?
1
2
ii.
Clindamycin 600 mg orally one hour before procedure?
1
2
iii.
Other?
1
2
_________________________________________________
_________________________________________________
5.
Any change(s) in any medications since the last WIHS visit (i.e., the core WIHS visit which occurred
within the last two weeks)?
YES ............................................... 1
NO ................................................. 2 (6)
a.
What change(s)? _________________________________________________
6.
Any treatments for oral lesions identified at the last WIHS visit (i.e., the core visit which occurred in the
last two weeks)?
YES ............................................... 1
NO ................................................. 2 (7)
a.
What treatments? _________________________________________________
7.
Any hospitalizations, clinic or doctor's office visit since last WIHS visit (i.e., the core WIHS visit which
occurred within the last two weeks)?
YES ............................................... 1
NO ................................................. 2 (8)
a.
What for? _______________________________________________________
8.
Excluding the WIHS clinic, where does participant usually go for dental care?
a.
Dental Care Provider: ______________________
Address: ___________________________________________________
b.
When was your last dental visit? _______________________________
c.
What did you see the dentist for? ______________________________
WIHS Form: OP1 - Oral Protocol Medical Evaluation - 10/01/98a
Page 3 of 3
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