Pre-Surgical Dental Clearance Medical History Form

This pre-surgical dental clearance medical history form is essential for patients undergoing major surgical procedures, particularly cardiac valve replacements, joint replacements, and other surgeries requiring prosthetic implants. Oral bacteria and untreated dental infections can lead to serious post-surgical complications including prosthetic joint infections and endocarditis. This form systematically documents the patient's current oral health status, recent dental work, active infections, and risk factors that surgical teams need to address before proceeding with elective procedures.

The template captures comprehensive information about dental pain, abscesses, loose teeth, gum disease, recent extractions, and ongoing dental treatments. It screens for conditions that increase infection risk such as poor oral hygiene, tobacco use, immunosuppression, and diabetes. The form also documents the patient's dental care history, last dental examination date, and any prophylactic antibiotic requirements. This information enables dentists to provide thorough clearance assessments and recommendations for pre-operative dental interventions, ensuring patients enter surgery with optimized oral health and minimized infection risk.