1

Informed consent for medical investigation, treatment or operation: Bariatric Surgery

Dear Patient! Most of surgical procedures proceed without any complications. Surgeries with local/general anaesthesia can cause complications, which you have to know, before agreeing for the treatment. To assessment individual risk you should inform the surgeon about your health. The doctor will clear you up about typical risks and consequences, alternative treatments, necessity of the surgery and details of the treatment course. Surgical operations to treat morbid obesity include gastric bypass, gastric sleeve and other procedures. Access to the abdominal cavity can be through standard surgical incisions or via laparoscopy. However, bariatric surgery is only one step in the process of weight reduction and many other medical disciplines contribute to achieving a good outcome. In the preoperative, surgical and postoperative phases of treatment, other caregivers play an important role, including: nurse consultants, dieticians, nutritionists and social workers. 1.Personal contact details Family name First name Date of birth Address Post Code Country Phone Mobile Email Height Weight Blood group ___________________________

2.Doctor (This section to be completed by the doctor) Type of Operation/Investigation/Treatment _________________________________________ I confirm that I have explained the above operation, investigation or treatment and such appropriate options as are available, and the type of anaesthetic proposed (general anaesthesia), if any, to the Patient in terms, which in my judgement, are suited to the understanding of the Patient. Print name Signature Date

3.Patient (This section to be completed by the Patient) Please read this form and attached notes very carefully. If there is anything that you do not understand about the explanation, or if you want more information, you should ask the Doctor named above. Please check that all information on the form is correct. If it is, and you understand the explanation, then sign the form. 4.Declaration

___________________________ I am the Patient/Parent/Guardian. ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________GP______________ I have told the Doctor about any additional procedures I would not wish to be carried out straightaway without my first having the opportunity to consider them (as specified here): I agree with what is proposed and has been explained to me by the Doctor named on this form and with the use of the type of anaesthetic I have been told about. I understand that any procedure in addition to the investigation or treatment described on this form will only be carried out if necessary and in my best interests/ the best interests of the patient and can be justified for medical reasons. Alternative methods and their benefits and disadvantages have been explained to me.

2 ______________________________________ ______________________________________
I was informed that the international standard for bariatric surgery (USA-NHI,1991) is a minimum of BMI 35 (with co-morbidity) or BMI 40 (without co-morbidity). If my BMI is lower than this international standard, I nevertheless decide to go for the surgery and take full responsibility for the indication for obesity surgery myself. I was informed that the surgery will be done under general anaesthesia. I understand that I will undergo additional counselling related to dietetics, rehabilitation and other services as deemed necessary by my physicians. I agree with the type of lap-band that the doctor/surgeon has chosen to place. This band has to have a CE accreditation. I understand that as a result of my chronic preexisting medical condition, I am at a great risk for any or all of those complications to occur. I understand and accept the risks of blood transfusions that may be necessary. I understand that tissue cannot heal without scarring and that how one scars is dependent on individual genetic characteristics. The physician will do his/her to minimize scarring but cannot control its ultimate appearance. I understand that the doctor may, at any time before or during the procedure, end the surgery. I am aware that smoking during the pre and postoperative periods could increase chances of complications. I have informed the doctor of all my known allergies. I have informed the doctor of all my metabolic diseases (diabetes, hyperthyroidism, hypothyroidism, kidney diseases), neurological diseases, psychiatric disorders, heart diseases, vascular diseases, arrhythmias, hypertension, infectious diseases (hepatitis A,B,C, HIV). For female patients only: I confirm I am not pregnant. I have informed the doctor of all medications I am currently taking, including prescriptions, over-thecounter remedies, herbal therapies and supplements, aspirin, and any other recreational drug or alcohol use. I have been advised whether I should avoid taking any or all of these medications on the days surrounding the procedure. I am aware and accept that no guaranties about the results of the procedure have been made. I have been informed of what to expect postoperatively, including but not limited to: estimated recovery time, anticipated activity level and the possibility of additional procedures. I understand that I should not become pregnant until one to one and one-half years after this surgery. The doctor has answered all of my questions regarding this procedure. The doctor can appoint associates or assistants and dieticians of his/her choice to help him during this procedure. Patient/Parent/Guardian Print name Signature Date

7.Additional specific notes on bariatric surgery There is no guarantee of surgical approach (laparoscopy, laparotomy) during the operation as well as there is no guarantee of weight loss maintenance after the bariatric procedure is reversed. Bariatric procedures including reversals, might be associated with higher risk of immediate or long term serious complications (as has been explained prior to operation). I understand that non-compliance to medical advices may lead to serious and life-threatening complications. Patient/Parent/Guardian Print name Signature Date

3
8.Standard consent form for medical investigation/treatment or operation Gastric Bypass A small stomach pouch is created to restrict food intake. Next, a Y-shaped section of the small intestine is attached to the pouch to allow food to bypass the lower stomach, the duodenum (the first segment of the small intestine), and the first portion of the jejunum (the second segment of the small intestine). This bypass reduces the absorption of nutrients and thereby reduces the calorie intake. Initials Tube/Sleeve Gastrectomy This is a relatively new approach. It is the first component of the duodenal switch operation and involves removing the lateral 2/3rds of the stomach with a stapling device. It can be done laparoscopically ( keyhole surgery) but is not reversible. It basically leaves a stomach tube instead of a stomach sack. Initials Revision of the Previous Weight Loss Surgery Revision of previous weight loss surgeries increases operative time and complication rates. Procedures that commonly occur in patients who need revision surgery include, but are not limited to, removal of part of stomach, placement of a drain, placement of a G-tube, and endoscopy. In case of previous lapband procedure reversal, the surgeon will remove the old lap-band and the port. Initials Lysis of Adhesions In the setting of a previous operation or significant abdominal infection, scarring always results. The degree of scar tissue is unpredictable. Sometimes, depending on the location of the scar tissue, the scar tissue must be cut (called lysis of adhesions) in order to perform the operation. There are increased risks when a lysis of adhesions is necessary including injury to the intestines, prolonged operative times, and bleeding. Initials Other Actual risks of the operation vary from person to person. Initials Death (extremely rare) The Bariatric Centre has never had a death associated with any surgery procedure. The mortality rate nationwide is less than 0,2%. I realize, and my family members realize, that every bariatric surgery is a major surgery and complications of this procedure can be fatal. Initials Significant Bleeding (very rare) Usually during the course of a bariatric surgery operation, less than 1 ounce of blood is lost. Bleeding may occur unexpectedly in the operating room. Bleeding may also occur post-operatively in the days after the operation. A transfusion may be necessary in some extremely rare circumstances. Reoperation to stop bleeding may be necessary. Placement of a Drain A drain is a thin plastic tube that comes out of the body, into small container to allow for the removal of fluid and the control of infection. The doctor does not routinely place a drain after the adjustable gastric band removal. However, in certain rare circumstances, the doctor may elect to place a temporary plastic drain. Initials Unpredictable complications Medicine is an unpredictable field. No amount of pre-operative testing can assure an uncomplicated outcome. The doctors attempt to minimize any possible chances of misdiagnosis - however, no physician or group of physicians are infallible. I have the responsibility to inform the doctors of any concerns, worries or possible complications at the earliest possible time. I agree that my doctors may make recommendations and I take full responsibility if I do not follow these recommendations. Initials

4
Initials Nausea The most common cause of post-operative nausea is pain medication. Many patients have nausea the day of their operation. Rarely, nausea will persist for a week. In rare cases, nausea will persist for longer. Initials Prolonged Ventilation (very rare) A patient requiring a prolonged stay on a ventilator (breathing machine) in the intensive care is rare. This may occur for example in very large patients with severe sleep apnoea or after certain significant complications. In these very rare instances, a temporary tracheotomy may be necessary. Initials Heart attack Although a heart attack is possible, it is very rare. Many patients undergo testing to assess the heath of their heart before their procedure. Some patients are asked to obtain cardiology clearance before proceeding with the operation. However, no amount of testing can eliminate the risks of a heart attack. Risk factors for heart disease include increased age, diabetes, hypertension, hypercholesterolemia and a family history of heart disease. Initials Prolonged Hospital Stay(uncommon) Unforeseen complications may result in a prolonged hospital stay. Intensive care admission may be required. Initials Medical Consultations My doctors reserve the right consult medical physicians to assist in my care when necessary. Initials Deep Vein Thrombosis (DVT)/Pulmonary Embolism (rare) Blood clots that form in the legs, and elsewhere, and break off into the lungs are a leading cause of death in this country after any surgical procedure. The doctors will do everything they believe possible to decrease the risk for the formation of blood clots. This includes the use of intravenous heparin ( a medication that thins the blood), special foot and leg stockings, walking soon after surgery and sometimes even the use of medication at home after discharge from the hospital. Despite all of these efforts, it is impossible to eliminate the risks of DVT (clots) altogether. There is also a possibility that the medications used to prevent blood clots can cause excessive bleeding. Any symptoms of leg swelling, chest pain or sudden shortness of breath should be immediately reported to the surgeon. My doctors usually use a means of DVT prevention that is not standard practice in the community. My doctors believe, and have the personal experience, that strongly suggests that their means of DVT prevention is ideal for the bariatric patient and is at least as good if not better that standard DVT prevention used in the community. Rare patients develop allergies to heparin sometimes causing very severe reactions. Initials Complications that may be common Allergic reactions to medications, anaesthetic agents or solutions used. Headaches, itching, medication side-effects, heartburn/reflux, bruising. Anaesthetic complications, sore throat, dizziness, blurred vision, shivering. Injury to the bowel, vessels or abdominal organs during the procedure, gas bloating. Minor wound problems are not infrequent. Minor drainage from the wounds, or even the wounds opening, may occur. Although scars from the laparoscopic procedure are usually small we cannot predict how any patient will form scars. Wound infections should heal over time but may cause a visible scar. Abscess formation, blood clots, blood vessel injury, bowel obstruction, cardiac complications such as cardiac arrhythmias or cardiac arrest, dehiscence, dehydration, severe bloating of the stomach; ulcers, leaks at the gastric stapling line, gastric fistula, haemorrhage from any site but especially within the operative area, infections generally at the wound site, but may occur elsewhere, inflammation, nerve injury, reflux, nausea, vomiting, difficulty swallowing, organ injury, especially spleen or diaphragm, stomal stenosis, various respiratory difficulties, hernia, gallstones due to rapid weight loss in a short period,

5
intestinal blockage, nutritional deficiency, inadequate weight loss, osteoporosis, depression, death. Initials Lap-band complications that may be common Band slippage, erosion of the band, deflation, infection of the port site, port leaking or twisting, obstruction of the stomach, stoma blockade, dilation of the oesophagus, pulmonary embolus, does not limit intake of high calorie or liquids or sweets; in standard procedure the lap-band is not filled during the surgery, only occasionally in special cases; a first fill is advised at earliest 6 weeks after surgery. Initials Open procedure If, for unforeseen reason, my operation is performed open, I am at higher risk for several complications. This includes wound infection which may cause significant scarring and healing problems, require prolonged wound care and cause discomfort. Incision hernias occur in approximately one-third of patients after an open gastric bypass. Hernias will require an operation to repair. Hernias can cause bowel obstructions and severe consequences if left untreated. There is a higher chance of certain complications including lung infections, pressure ulcers and blood clots after an open operation. There would also be predictably more discomfort and a longer hospital stay. Initials Weight regain There is no guarantee of weight loss after any bariatric procedure. Even weight regain may occur after bariatric operation. Initials Unforeseen problems Although this procedure has been performed for many years, there may be long-term problems not known at this time. I understand that unforeseen events may occur that would result in the last minute cancellation or postponement of my operation. My doctor will only cancel my operation in the case of emergency conflicts or if it is my best Unlisted complications I understand that it is impossible to list every complication possible during and after this procedure. I agree that my doctors have done their reasonable best in listing the most significant complications that may occur. Initials Fees I am responsible for fully understanding all the fees that I may incur. The clinic has no responsibility or control over the billing and financial obligations related to the treatment in any other medical facility either in Poland or in the patients country. The Clinic is not responsible for predicting my hospital charges. I take full responsibility to understand all potential hospital costs. If complications of surgery or significant modifications of surgery occur during or any time after the planned operation, I understand that additional, significant, professional fees may apply. Initials Other Bariatric Surgery is a vast discipline. There is no way that my doctors can teach me everything about these procedures. There is no way that my doctors can predict all possible outcomes. This consent is not meant to be all inclusive. Complications or problems may arise that were not specifically addressed. I have reviewed all of the information in this consent form with my immediate family. I have clearly started to my closest family that I fully understand the risks of surgery and believe that the risks are acceptable. Any conflicting information on the risks and benefits of surgery implied form any other format (internet, brochures, video, and physician interview) is to be superseded by this legal document. Initials interest for safety. My doctors are not financially responsible for any costs incurred by rescheduling my operation for any reason. Initials

6
9.Contract I am the Patient/Parent/Guardian. This contract shall be subject to the laws of Poland (Accordance to the act of the 6 November 2008 about the rights of the patient and the patients advocate, chapter 5, article 17, act 2) and constructed in all respects as a polish contract. If any sections of individual terms of this stamen are found at any point to be non-enforceable or incorrect, the content of validity of the remainder of this document will not be affected. I declare that I was fully informed by-------------------------------------------------------------------(Doctor), I understand the procedure of the planned treatment/surgery and the possible necessity to extend the surgery. I had the opportunity to ask any questions regarding the nature and course of the planned treatment/surgery, my individual operational risks, possible (early and late) complications, alternative treatment options and I received all and comprehensive answers. I declare that I do not have any other questions , I am fully informed and I agree for the treatment/surgery, after a period of reflection. I agree for possible changes by enlargement or reduction of the planned treatment/surgery only with justified occurrence of unforeseen circumstances or the necessity of adjustment to the scope of operatively to identified diseases. I authorize -----------------------------------------------, M.D, and associates of his/her choice to perform a -------------------------------------- (type of procedure), laparoscopic/open (circle one) on ---------------------------------------------------------------(Patient name). I certify that I have read, or had read to me the content of this form and understand this treatment agreement. All blanks were filled in prior to my signature. Print name Signature Date I gave/ the Patient has been given sufficient information, in a way I/ he can understand, about the proposed treatment: ____________________ and the possible alternatives. I have explained the nature, purpose, benefits, risks and complications of the procedure to the Patient. Consent given for one procedure or episode of treatment does not give an automatic right to undertake any other procedure. A consultant may however, undertake further treatment if the circumstances are such that a patients consent cannot reasonably be requested and provided, the treatment is immediately necessary unless the Patient has previously indicated that the future treatment would be unacceptable. Print name Signature Date Doctor (This section to be completed by the doctor)

10.Contract addition 1.These Standard terms and Conditions stipulate the provision of medical care at the KCM Clinic S.A., registered address ul. Bankowa 5-7, Jelenia Gra, 58-500, Poland. The Clinic/Hospital is a fully accredited healthcare provider under laws and regulations of Poland. All the surgeons and consultants employed at the KCM Clinic S.A. are fully qualified and entitled to the provision of healthcare services under laws and regulations of Poland. Pre-operative Tests and Consultations 2.A rare, but possible, result of the pre-operative tests is that they may reveal circumstances (medical or otherwise) which could complicate the operation, posing an increased risk to the person undergoing surgerys (hereafter known as the Patient) health. In such case, the Clinic would not undertake the surgery. The Patient, in such circumstances, required to pay the Clinic a fixed fee of EUR 100, in order to reimburse the cost of the tests. This payment must be made by the Patient before their departure from the Clinic. 3.Informed Consent for Medical Investigation, Treatment or Operation(hereafter known as the Consent) includes the Standard Terms and Conditions and must be approved by the Patient

7
prior to their surgery. Failure to agree with these, or the withdrawal of the Patients consent for the surgery, will result in termination of the procedure. The patient will also be required to pay the Clinic a fixed fee of EUR 100, in order to reimburse the cost of the consultation. This payment must be made by the Patient before their departure from the Clinic. 4.Prior to the performance of the operation the Clinic will perform a gastrofiberscopic examination of the Patients stomach area. Performance of such a test is included in the price for the Procedure. Should this examination identify any medical condition(s), like ulcers or other stomach malfunctions, which contraindicate the Procedure or increase the risk of complications, the Clinic will not proceed with the operation on medical grounds. The Patient will in such case reimburse the Clinic the costs of the pre-operative tests as stated in the paragraph 2 above and the costs of the gastrofiberscopic examination of the stomach area of EUR 350. In extremely rare circumstances, a medical condition contraindicating the procedure is identified by the surgeon only after the operation has commenced by visual examination of the inner organs. The Patient agrees and understands that in such a case the operation will be ended and agrees to reimburse the Clinic the costs incurred of EUR 400. 5.The Patient is required to cover the cost of any extra pre-operative tests deemed necessary for their surgery. Such tests will be justified and undertaken by the Clinic on medical grounds; the Patient will be given a clear and comprehensive summary of their requirements and costs beforehand. The Patients consent is required for such additional tests. 6.The Patient agrees to the recording of their preoperative consultation(s) with their surgeon(s). This recording is necessary for subsequent clarity in all matters pertaining to the Patient and their procedure. Any refusal to permit such recording may result in the Clinics termination of the procedure and, subsequently, the patient will be unable to claim any resulting costs incurred. Print name Signature Date

Post-Operative Care 7.Following their operation and before departing the Clinic, the Patient will be given the relevant instructions and recommendations pertaining to their post-operative care (hereafter known as the Instructions). It is vital that the Patient reads and understands the Instructions and follows them in every detail. Failure to do so may result in aesthetic deterioration following the procedure; furthermore, the Patient may be endangering their health or, at worst, risking their life. Failure to provide the Clinic with completely accurate and up-to-date information about their state of health carries the risk of deteriorating aesthetic effects and a danger to health. The Clinic cannot guarantee the results of any procedure undertaken in either of the above circumstances. 8.Following their operation, the Patient is obliged to provide the Clinic with photographic evidence, detailing the stages of their recovery, of the operated area (and the port area, where applicable). These photographs must be digital, with the accompanying date, and are required at the following post-operative stages: 2 weeks, 4 weeks, 3 months. The Patient may submit this evidence to the agency organising their procedure (hereafter known as the Arranging Agency). In addition, further photographic evidence may be necessary; each case is considered individually by the Clinics specialist. Failure to provide any of the aforementioned photographic evidence may negatively affect the impact of any subsequent corrective work or operations performed on the Patient. 9. The Clinic has the Patients authorisation to submit all information and documents pertaining to them and their procedure (including medical notes, photographic evidence and copies of relevant paperwork) to the Arranging Agency. These are required for the Patients post-operative care and support undertaken in their country of residence. Furthermore, the so-called before and after photographs of their procedure may be required for medical use by the Clinic; the Patient authorises this usage. 10.Before seeking any kind of medical assistance the Patient must first contact the Clinic. Subsequently, the Clinic will provide their

8
acceptance, in writing, of any required treatment and the Patient is then free to make their own choice of healthcare provider. This does not apply in life-threatening situations. Print name Signature Date 15.Any other costs than those specifically mentioned in the paragraph 14 above, which may crystallise in connection with the corrective procedure, are not under any circumstances to be covered by the Clinic or any other third party and are solely borne by the Patient. Such costs include, inter alia, travel costs including flight tickets, accommodation after the stay at the Clinic, any costs related to any other person(s) accompanying the Patient, insurance and so forth. Additional Provisions for Laparoscopic Greater Curvature Plication 16.The Clinic may cover only immediate, surgical complications directly relating to the surgery. This includes an immediate re-operation and/or prolonged hospitalisation. The Clinic is not obliged to cover the cost of any complications not directly related to the surgery, which must be covered by the Patient. The cost of any re-operation that is required as a result of non-surgical related complications are between approximately EUR 2000 and 4000 and include the standard preoperative tests and the required stay at the Clinic. Print name Signature Date

Customer Complaints 11.The Patients visual satisfaction with the results of their procedure will naturally vary, within 3 to 4 months of the operation is the standard length of time although full recovery and satisfaction may take up to 12 months. Taking this into account, should the Patient feel that the results of their procedure are unsatisfactory as a direct result of error or omission on the part of the Clinic, they must immediately contact the Clinic to express their dissatisfaction (hereafter known as the Complaint). Their Complaint must be made in writing, attaching high quality photographic evidence (complete with date) of the relevant area. 12.The Clinic will, immediately upon receipt of the Complaint, undertake an evaluation of the Complaint. The decision on appropriateness of the Complaint will be made by the Clinic specialist and subsequently reviewed and authorised by the head surgeon of the Clinic. The Clinic will judge medical reasons of possible corrective procedure and communicate the conclusion in writing, with full reasoning, to the Patient within 10 working days of the date of the receipt of the Complaint. 13.Any corrective procedure agreed to by the Clinic as a result of the formal evaluation of a Complaint, as described in Paragraph 11 above, will usually, for medical reasons, be carried out within 6 to 12 months of the original operation date. Print name Signature Date

Limitation of Liability 17.No injury, damage, loss, delay, additional expenses or inconvenience caused by external forces beyond the Clinics control or prevention will be taken responsibility for by the Clinic. Furthermore, the Clinic will not be held liable for any medical conditions which were not identified by the necessary pre-operative tests undertaken on the Patient with due care and diligence by the Clinic. For any unexpected events, or those that could not have been reasonably foreseen, the Clinic cannot bear liability. 18.If the Patient fails to meet any of the obligations specified in the Standard Terms and Conditions, the Clinic cannot be held liable or bear the cost of any corrective treatment. This includes the following: failure to follow, in detail, the Instructions (as detailed in paragraph 7 above); failure to provide their operation (as detailed in paragraph 8 above); failure to contact the Clinic before finding a different healthcare provider (as detailed in paragraph 10 above).

Corrective Procedure Costs 14.Any corrective work carried out by the Clinic as the direct result of the evaluation procedure of a Complaint, as described above, will be carried out free of charge. The standard time required for the Patients recovery at the Clinic, is also free of charge.

9
Print name Signature Date Nervous breakdown Nose/throat problems Pneumonia Rheumatic fever Shortness of breath Stomach problems Please provide us with the name of your doctor: _________________________________________ May we have permission to contact your physician if it is necessary? Location/Phone number:_____________________ Medical conditions: Are you/ have you ever had: AIDS/HIV positive Arthritis Back problems Blood disorders Breathing problems Chest Pain Depression Ear problems Epilepsy Heart Murmur High/Low blood pressure Kidney problems Migraine/ headaches Anemia Asthma Blood Clots Bleeding Problems Cancer Colitis Diabetes Do you use insulin? Eye problems Heart problems Hepatitis Irregular heartbeat Liver problems Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Thyroid problems Transfusion Osteoporosis Any psychiatric conditions Seizures Skin Cancer Stroke Tuberculosis Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

11.Pre-operative questionnaire for adults Bariatric Surgery Patient (This section to be completed by the Patient)

Have you had any trauma such as divorce, loss of someone close to you, or anything else that caused higher than usual stress in your life within the past year? Yes/No Do you take birth control pills or any hormone replacement medication or patches? Yes/No Are you within childbearing years? Medical history: Within the past 18 months have you been hospitalized, had surgery or received medical care for anything including inpatient or out-patient, ambulatory surgery or delivery of a pregnancy? Date of surgery: Reason for surgery: Have you ever had weight loss (bariatric) surgery: Which procedure did you have: Date of surgery: Weight change since surgery: Do you have any implants or metal objects in your body such as pacemaker? Yes/No Plates or screws or any other hardware from an orthopaedic procedure? Yes/No Total Hip Replacement/Resurfacing or Total Knee Replacement? Yes/No Please list any other past surgeries: _________________________________________ Do you form keloids or have any difficulty with healing or scarring? Yes/No Have you had previous cosmetic surgery? Yes/No Yes/No

10
Have you had an operation under local or general anaesthetic? Yes/No Date:_____________________________________ Have you any members of your family ever had problems with anaesthetics? Yes/No Details:___________________________________ Have you had an unusual reaction in the past to an anaesthetic? Yes/No List all Medications you currently take along with the dosage. (Please also indicate if you are taking any BCP's): _________________________________________ _________________________________________ Are you allergic to any medication? If yes, give the name of the medication and describe your reaction: _________________________________________ _________________________________________ Have you ever had problems with anaesthesia? Yes/No Do you have any food, environmental, or other allergies or allergy to latex? If yes, list allergens and describe your reaction: _________________________________________ _________________________________________ List Vitamins, Herbs or other Nutritional Supplements you take: _________________________________________ _________________________________________ Have you ever taken an MAO inhibitor such as Nardil, Marplan, or Parnate? If yes, when was your last dose? Date:_____________________________________ Have you ever taken an anticoagulant such as Coumadin, Heparin , or a daily aspirin? If yes, when was your last dose? Date:_____________________________________ Have you ever smoked tobacco? Yes\No How much do you smoke now?________________ When was your last cigarette or tobacco product (patch, gum, inhaler or cigarette)? Date:_____________________________________ Do you drink alcohol? Yes/No How much? ______________________________ Do you use recreational drugs? Yes/No How much? _______________________________ What is your average blood pressure?_____/______ Do you get breathless quickly or do you get chest pain when you exert yourself? Yes/No Do you ever have swollen feet and legs in the evening? Yes/No Do you have varicose veins? Have you ever had phlebitis? Yes/No Yes/No

Do you suffer from any breathing disorders, asthma or chronic bronchitis? Yes/No Are you currently receiving treatment for a nervous disorder? Yes/No Are you currently receiving treatment for an eye disorder? Yes/No Have you had the flue recently (over the last month)? Yes/No Have you had recently a cold? Yes/No

The following question is for women under the age of 50 only. When did you have your last period? _____________/________________/___________ Do you suffer from any other disease or disorder not mentioned here? Yes/No _________________________________________ Do you suffer from prolonged bleeding after an injury or dental extraction? Yes/No _________________________________________ Do you ever received a blood transfusion? Yes/No Have you ever had any adverse reaction to a blood transfusion? Yes/No Do you have dentures or loose teeth? Do you wear contact lenses? Do you wear a hearing aid? Yes/No Yes/No Yes/No

Have you ever had a prosthesis or implant fitted? Yes/No Do you have difficulty making certain movements, which are not related to the operation? Yes/No Additional information: _________________________________________ _________________________________________ _________________________________________ It is important that you never withhold any information about your health issues from KCM Clinic, your doctor or dentist. If there are any health matters not covered in this questionnaire that you think might be pertinent to your state of health, please list them here: ________________________________________ Print name Signature Date

11