IV Conscious Sedation Oral Surgery Step 1 of 9 11% GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH WHAT IS AN IMPACTED TOOTH? An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them. An impacted tooth is one which has been prevented from erupting into the mouth. The tooth may be blocked by another tooth, or dense bone or a pathological condition. Any tooth can be impacted, but more often than not, impacted teeth are wisdom teeth or third molars as dentists call them. WHAT HARM CAN IMPACTED TEETH DO? Impacted teeth may grow in any direction; however they often grow forward and push against the adjacent second molar. This can result in pain in the second molar and possibly damage to the roots or crown. The second molar may also be pushed out of position. All teeth develop in sacs deep in the bone. If the tooth erupts normally, the sac generally disappears. If the tooth is impacted, the sac can fill with fluid and enlarge to form a cyst. The cyst can cause destruction of surrounding bone and damage to other teeth in the area. Whenever saliva can reach the tooth, decay may occur, and since such cavities cannot be filled severe pain may result. This may be followed by the formation of an abscess. Bacteria in the saliva may cause an infection around the crown of the wisdom tooth and under the flap of gum tissue which may be covering part of the tooth. This infection may spread to the cheek, throat or neck and result in severe pain, stiffness of the jaws, fever, and severe generalized illness. Pressure from the wisdom teeth may cause crowding of the front teeth. This is why some orthodontists do not consider orthodontic treatment complete until impacted third molars have been removed. WHEN IS IT BEST TO HAVE WISDOM TEETH REMOVED? The dentist can study x-rays of the teeth and jaws, and can frequently tell by the teen years if the wisdom teeth are going to be impacted. At this stage the roots are usually not fully formed in most people and the bone is less dense. Therefore, the wisdom teeth are less complicated to remove and the healing is generally faster. WHAT IS IT LIKE TO HAVE AN IMPACTED TOOTH REMOVED? Because the impacted tooth is usually completely beneath the surface of the gum and often encased in bone, we consider its removal an operation in every sense of the word. This is said not to frighten the prospective patient, but rather to give a better understanding about certain features regarding cost, careful preparations and the need for good aftercare. Either local and general anaesthesia or local and sedation may be used. The dentist chooses the method of treatment based on each individual situation. Having a comfortable patient helps to control bleeding, allows the dentist to work without haste and causes less physiological disturbance to the patient. The actual removal of the tooth is done in keeping with recognized surgical principles, with meticulously sterile instruments, good light, a dry operative field, gentle handling of the soft tissue and bone and the advantages of a well trained team. Depending on the degree of difficulty of the individual case, the procedure may last from fifteen to sixty minutes. If sedation or general anaesthesia is used there will be a recovery period from thirty to ninety minutes. The surgical wound may be sutured with a material of the dentist’s choice. Most often dissolving sutures are used. WHAT SHOULD I EXPECT AFTER SURGERY? After any surgical procedure a certain amount of discomfort is anticipated. For this reason you will be provided with pain relieving medication before you leave the office. You are to take your pain medication as directed by the dentist; instructions will be on the bottle. Your dentist will decide if antibiotic medication is necessary and if this medication has been prescribed then it should be taken until all tablets are gone. Swelling after surgery is normal. You should expect to be most swollen forty eight to seventy two hours after surgery. The swelling then begins to resolve. Certain individuals have bruising after wisdom teeth surgery. The bruising may extend into the neck and chest. This should not alarm you as in some individuals this is the normal sequence of events. Stiffness of the jaws is also normal after wisdom teeth surgery and is usually at its worst two or three days after surgery. One should start to exercise the jaws on the second or third post operative day to return the jaws to normal. Although it will probably be difficult to eat after surgery in the mouth one must remember that the body heals itself by drawing upon its reserves of protein, vitamins, minerals, calcium and iron. Failure to replenish the body’s supplies of the above mentioned nutrients can result in fatigue, infections and even delayed healing. For the first twenty-four hours following surgery your food and beverages should be warm or cold NOT HOT. Eggs, custards, yogurt, milkshakes, baby food, etc., are both nutritious and manageable. Fluid intake should be approximately two litres or eight juice glasses per day for the average adult. Detailed post operative instructions will be provided before you leave the office. ARE THERE ANY COMPLICATIONS OR RISKS? Any operation carries some degree of risk. This risk is minimized by careful preoperative assessment of your physical condition, by careful examination of all of the diagnostic materials, by careful preparation of instruments and all facilities, and by the skill of your dental team. The most commonly encountered complications will be discussed below. Post-operative bleeding is usually encountered when the patient has not placed the gauze pack DIRECTLY over the surgical site. Pressure over the site for forty-five to sixty minutes will control most post-operative bleeding. If you are still concerned call the office and the problem will be dealt with promptly. A condition known as dry socket occurs in approximately five percent of patients. It is more common in smokers and in female patients on the pill. It is manifest by a dull throbbing pain which starts five or seven days after the operation and is accompanied by a foul odour from the mouth. The treatment for this problem is simple and consists of two or three dressing changes. Healing is slightly slower than normal. The roots of lower impacted teeth very often rest on and around the main nerve of the lower jaw. Very rarely, in spite of all precautions, during the removal of lower third molars this nerve is bruised, slightly lacerated or even severed. The result will be numbness of the lower lip, chin, and all of the teeth on that side. This effect does not last longer than a few weeks in most cases. It improves as the nerve repairs itself and regenerates. Occasionally the numbness may last as long as two or five years and even more rarely it may be permanent .Also in the region of the lower third molar is the nerve which supplies sensation to the lateral part of the tongue. It may on occasion be stretched with a resultant numb tongue. This problem usually resolves within several weeks or months. Upper impacted third molars lie against the wall of the sinus. Great care is taken to insure that no injury occurs to this structure but occasionally the thin wall of bone cracks and blood seeps into the sinus. Occasionally there may be formed a communication between the sinus and the mouth. If your dentist suspects this to be the case you will be informed and additional medication will be prescribed. Infections after the removal of wisdom teeth are rare. Redness, increasing swelling after an initial decrease, foul tasting discharge into the mouth, fever and chills are all signs if infection. If these should appear call the office and you will be attended to promptly. Occasionally large fillings in the second molar teeth may be loosened or cracked during the removal of the wisdom teeth in spite of immaculate care and skill. If the possibility of this exists prior to surgery, you will be informed. Another very rare complication is a cracked or fractured lower jaw. This occurs when the wisdom tooth is very severely impacted. If your dentist is concerned about this possibility, you will be informed. Dr. Brian Kumer416 605-0008 GENERAL INFORMATION REGARDING REMOVAL OF IMPACTED AND UNERUPTED TEETH I acknowledge that I have read this document ORAL SURGERY CONSENT FORM SWELLING, BRUISING AND PAIN These can occur with any surgery and vary between patients and from one surgery to another. You may require several days at home for recovery. You may also have stretching of the corners of the mouth that may cause bruising and may heal slowly. TRISMUS This is the limited opening of the jaws due to inflammation in the muscles. This is more common with impacted tooth removal but is possible with almost any surgery. There is a higher likelihood if TMJ (see below) problem already exists. INFECTION This is possible with any surgical procedure and may require further surgery and/or medications if it does occur. BLEEDING Although significant bleeding can occur during or after surgery, it is not common. Some bleeding is, however, expected with most surgeries and is normally controlled by following the post-op instruction sheet. Prolonged or heavy bleeding may require additional treatment. TMJ DYSFUNCTION This means the jaw joint (Tempromandibular Joint) may not function properly and, although rare, may require treatment ranging from use of hot/cold compress and rest to further surgery. LOCAL ANAESTHESIA Certain possible risks exist that, although uncommon or rare, could include pain, swelling, bruising, infection, nerve damage, idiosyncratic or allergic reactions. ALLERGIC REACTION Allergic reaction, such as itching, rash, swelling, difficulty in breathing, is possible to any medication used it treatment. DRY SOCKET This is significant pain in the jaw and ear due to the loss of the blood clot and most commonly occurs after the removal of lower wisdom teeth, but it is possible with any extractions. Incidence increases with poor oral hygiene, smoking, birth control pill use. This may require additional office visits to treat. DAMAGE TO OTHER TEETH AND FILLINGS Due to the close proximity of teeth, it is possible to damage other teeth and/or fillings when a tooth is removed SHARP RIDGES AND BONE SPLINTERS Occasionally, after an extraction, the edge of the socket will be sharp or a bone splinter will come out through the gum. This may require another surgery to smooth or remove the bone splinter. INCOMPLETE REMOVAL OF TOOTH FRAGMENTS There are times when the dentist may decide to leave in a fragment or root of a tooth in order to avoid doing damage to adjacent structures such as nerves, sinuses, etc. or if an extensive risk of other complications is present with its removal. NUMBNESS Due to the proximity of roots to the nerve (especially wisdom teeth), it is possible to bruise or damage the nerve with removal of a tooth. This could remain for days, weeks, or very rarely, permanently. The lip, chin, cheek, gums and/or tongue could feel numb, tingling or have burning sensation. SINUS INVOLVEMENT Due to the location of the roots (especially the upper back teeth) to the sinus, it is possible for an opening to develop from the sinus to the mouth. Or a tooth/fragment may be displaced into the sinus. A possible infection and/or permanent opening from the mouth into the sinus could develop and may require medication and/ or later surgery. JAW FRACTURE Fracture of the jaw, usually in more complicated extractions. QUALIFICATION Dr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED.ORAL SURGERY CONSENT FORM I acknowledge that I have read this document APPENDIX TO SURGICAL INFORMED CONSENTDr. Brian Kumer is NOT A SPECIALIST: NOT AN ORAL SURGEON OR PERIODONTIST. He is a general practitioner dentist whose practice focuses primarily on wisdom teeth extractions and dental implant surgery. A REFERRAL TO THE SPECIALIST HAS BEEN OFFERED AND DECLINED. IF YOU TAKE BLOOD THINNERS INCLUDING ASA DO NOT STOP TAKING THEM PRIOR TO YOUR DENTAL PROCEDURE. PLEASE CHECK WITH DR. KUMER FIRST. If you have any questions or concerns about your treatment, either the surgical/sedation aspects of the procedure or the consent forms please email [email protected] APPENDIX TO SURGICAL INFORMED CONSENT I acknowledge that I have read this document Ontario’s Narcotics Strategy List Of Approved Forms Of Identification Ontarians must provide personal ID to their doctor, dentist, and in certain cases the pharmacist, in order to receive prescription narcotics and controlled substance medications. Ontarians are also be required to present ID if they have been authorized to pick up prescription narcotics or other monitored medication for someone else. The information on your ID will be recorded and monitored to help to ensure proper prescribing and dispensing practices are being followed. Below is a list of forms of identification that a person can present to a prescriber or dispenser: Ontario Health Card or other health card issued by a Province or Territory in Canada Valid Driver’s Licence or Temporary Driver’s Licence (issued by Ontario or other jurisdiction) Ontario Photo Card Birth Certificate from a Canadian province or territory Government-issued Employee Identification Card Ontario Outdoors Card BYID (age of majority card) Certificate of Indian Status Valid Passport – Canadian or other country Certificate of Canadian Citizenship Canadian Immigration Identification Card Permanent Resident Card Canadian Immigration Identification Card Old Age Security Identification Card Canadian Armed Forces Identification Card Royal Canadian Mounted Police/Provincial/Municipal Police Identification Firearms Possession and Acquisition Licence Ontario’s Narcotics Strategy I acknowledge that I have read this document POST-OPERATIVE INSTRUCTIONS DR. BRIAN KUMER416 605 0008 PLEASE READ THESE INSTRUCTIONS CAREFULLY. Sometimes the after effects of oral surgery are quite minimal, so not all of these instructions may apply to you. Common sense will dictate what you should do. However, when in doubt, follow these guidelines or call us for advice. DAY OF SURGERY (FIRST 24 HRS) AND DAYS 2-7 FIRST HOUR Bite down gently but firmly on the gauze packs that have been placed on the surgical sites, making sure they remain in place. Do not change them for the first 30 minutes unless the bleeding is not being controlled. If active bleeding persists after 30 minutes, place enough new gauze to obtain pressure over the surgical site for another 30 minutes. The gauze may be changed as necessary and may be dampened for more comfortable positioning. Do not disturb the surgical area today.NO RINSING, WHATSOEVER, DURING THIS PHASE. DO NOT SMOKE. Smoking increases the risk of dry socket dramatically. OOZING/BLEEDING It’s normal to have your saliva stained with blood for a few days. There may also be some slight oozing. If this persists, place fresh gauze over the area and bite down for 30-60 minutes. Bleeding should never be severe. If it is, it usually means the gauze packs are placed between your teeth and not over the surgical sites. Try to reposition them. If this doesn’t work substitute a moistened tea bag wrapped in moist gauze for 30-60 minutes. Do not sleep with gauze in your mouth.When sleeping use an old pillow and place some towels around your head to protect your bedding. If bleeding remains uncontrolled please call us. SWELLING Often there is swelling/bruising associated with oral surgery. Swelling is a normal response to trauma. It is not the same as infection. If you are swollen this does not mean you are infected. You can minimize this by using an ice pack applied to the face adjacent to the surgical site. The ice should be applied for a 10 minutes per side every hour over a 24-48 hour period. After the first 24-48 hours, stop icing the area. Do not use ice packs while sleeping. Despite icing the area, swelling will still occur. After 48 hours, apply a warm moist compress for 10-15 min of several times a day for balance of the week. Swelling usually increases over a 72 hour period. Therefore you will appear more swollen on the 3rd day than the 2nd day. After 72 hours, swelling starts to slowly subside and is mostly gone by the 7th day. RINSING After the first 48 hours have elapsed you may stop icing the area. At this time start with warm salt water rinse. Place a teaspoon of salt in a glass of warm water. Gently swish it around your mouth 2-3 times a day for the next 7-10 days. Do not spit out the rinse. Let it fall out of your mouth. Spitting exerts a force on the healing clot and can slow down healing and promote bleeding. Do not use mouthwash for the first 7 days unless prescribed by the dentist. Also you may brush in the area unaffected by the surgery butleave the surgical areas alone for 7 days. After that you may gently clean around the area although swelling and soreness may not permit you to do so. In time, you will be able to return to proper oral hygiene care. PAIN Unfortunately oral surgery is usually accompanied by some degree of discomfort. You may have been given some pain medication prior to the start of your procedure. It is important to follow the instructions with pain medication as it is easier to “stay ahead of the pain rather than trying to catch up to it.” If you take the first pain pill before the local anesthetic has worn off you will be able to manage the discomfort better. INFECTION Unless you present with infection you usually don’t develop an infection in the first few days. Antibiotics are prescribed to either help prevent infections from developing or to treat an infection that is present. Not all procedures require an antibiotic. There is a decrease in effectiveness of birth control medication when taking antibiotics. Consult your physician for advice on additional birth control measures. Slightly elevated temperature may occur for reasons other than infection. Be sure to drink lots of fluids: 1.5-2 liters /day. DIET Soft food is the dietary choice for the first few days. Ice cream, Jell-O, pudding, mashed potatoes, soups, pasta, or baby food are good choices. Avoid foods like nuts, popcorn, and rice as they tend to get stuck in the socket areas. Drinks like ENSURE or BOOST are good supplements as well. DO NOT USE A STRAW OR DRINK FROM A BOTTLE for the first 2-3 days. This can exert a force on the blood clot and slow down healing and promote bleeding. Use a spoon or a cup. After the fourth day you can progress to solid foods at you own pace. It is important to eat as you will feel better and heal faster. If you are diabetic, maintain you normal eating habits as much as possible and consult your physician regarding your insulin schedule. STITCHES You may have had some stitches placed. They will dissolve on their own in 5-7 days.Not all surgical sites require stitches.If a stitch comes out it is of no concern provided there is no excessive bleeding. SMOKING Do not smoke!It is advisable not to smoke for at least 7days. SYRINGE You will be given an irrigating syringe at your appointment. Fill a cup with salt water and then fill the syringe. Gently place it in the LOWER SOCKET ONLY and irrigate it 2-3 times. Do this after each meal over the next three to four weeks until the sockets close up. DO NOT USE THE SYRINGE UNTIL 5 DAYS AFTER YOUR SURGERY! REST You need to give your body time to heal following surgery. No physical activity is recommended for 1-2 days if the procedure was minor and 5-7 if it was more involved. You need to give your body time to heal following surgery. No physical activity is recommended for 1-2 days if the procedure was minor and 5-7 if it was more involved. SHOULD YOU BE UNABLE TO REACH ME IN AN EMERGENCY, GO TO THE NEAREST EMERGENCY ROOM DR. BRIAN KUMER416 605 0008POST-OPERATIVE INSTRUCTIONS I acknowledge that I have read this document PRE-SEDATION INSTRUCTIONS IF YOU DO NOT FOLLOW THE IV SEDATION INSTRUCTIONS, YOUR APPOINTMENT WILL BE CANCELLED A: Do not eat or drink anything (EXCEPT WATER) for at least 8 hours prior to your appointment. B: You may drink water (ONLY), at least 3 hours before the appointment. If you need to take medications prescribed by your physician, TAKE IT WITH SIPS OF WATER ONLY, AT LEAST 3 HOURS prior to your appointment. You must have a responsible ADULT (relative or friend) escort you home in a car or taxi. You may not take public transit home! Please wear something short-sleeved (eg, t-shirt). Do not wear facial makeup or nail polish Do not drink grapefruit juice for at least 24 hours prior to surgery. Contact us prior to your appointment if there has been a change to your general health. IF YOU HAVE ANY OTHER QUESTIONS PLEASE CALL DR. BRIAN KUMER416 605 0008PRE-SEDATION INSTRUCTIONS I acknowledge that I have read this document POST SEDATION INSTRUCTIONS Do not drive or operate hazardous equipment for 24hrs after sedation. A responsible person should remain with the patient for 24 hours. Patients must not go up or down stairs unescorted for 24hrs. No unattended bath or shower for 24 hrs. Diet is restricted by surgical procedure not the sedation. Drink plenty of fluids, 1.5-2 litres per day in the first three to four days. Always hold patients arm when walking. Alert and sleepy patients need to be treated in the same manner. Don’t use any pillows for the first night. No alcohol for 24hrs Do not sign any important or legal documents for 24hrs. Call if you have any questions or concerns. If you feel that your symptoms warrant a physician and you are unable to reach us go to the nearest emergency room immediately. Following most surgical procedures there may be pain. You will be provided with a prescription for medication that is most appropriate for you. Antibiotics and Pain killers are the usual medications being prescribed, although antibiotics are not always required. Please follow the directions on the bottle of the medications. If you are taking any other medications and are concerned about drug interactions speak to the dentist or your pharmacist. DR. BRIAN KUMER416 605 0008POST SEDATION INSTRUCTIONS I acknowledge that I have read this document IVCS Consent Dr. Brian Kumer DDSConsent for I.V. Conscious Sedation This form is provided to inform you of the choices and risks involved in having I.V Conscious Sedation. The most frequent side effects of any intravenous sedatives are drowsiness, nausea and phlebitis.Most patients remain drowsy or sleepy following their surgery for the remainder of the day.As a result, coordination and judgement will be impaired.It is crucial that adults refrain from activities such as driving, and children remain in the presence of a responsible adult.Phlebitis is a raised, tender, hardened, inflammatory response at the intravenous site.The inflammation usually resolves with the application of a warm towel and anti-inflammatory medication; however, tenderness and a hard lump may be present up to a year. I have been informed and understand that occasionally there are complications of the drugs IV Sedation including but not limited to: pain, hematoma, numbness, infection, swelling, bleeding, discolouration, nausea, vomiting, allergic reaction, skin rash, respiratory depression/arrests, seizures, hallucinations,I have been made aware the risks associated with local anesthesia and I.V. Conscious Sedation, it must be noted that local anesthesia isappropriate for almost every patient and every procedure.Nerve damage from local anesthesia administration usually resolves, however, this may take over one year to heal.Nerve damage from local anesthesia administration may also be permanent. I understand that sedation medications, and drugs maybe harmful to the unborn child and may cause birth defects or spontaneous abortion.Recognizing these risks, I accept full responsibility for informing Dr. Brian Kumer of the possibility of being pregnant or a confirmed pregnancy with the understanding that this will necessitate the postponement of the sedation for the same reason, I understand that I must inform Dr. Brian Kumer if I am a nursing mother. Sedation medications and, drugs, and prescriptions may cause drowsiness that can be increased using alcohol or other drugs.I have been advised not to operate any vehicle or hazardous devise for at least twenty-four hours, or until fully recovered from the effects of the medications, and drugs.I have been advised not to make any major decisions until after full recovery from the sedation.Parents are advised of the necessity of direct parental supervision of their child for twenty-four hours following the sedation. I have been advised of and completely understand the risks, benefits, and alternatives of local anesthesia and conscious sedation.I accept the possible risks.I acknowledge the receipt of and understand both the preoperative and post-operative sedation instructions.It has been explained to me and I understand that there is no warranty and no guarantee as to any resultI authorize the exchange and sharing of my personal information between the treating doctor’s office and Dr. Brian Kumer. I consent to the administration of IV Conscious Sedation and other drugs as deemed necessary.I understand and agree to follow the “Patient Instructions” information as previously given to me.I have been explained the proposed treatment as presented to me.I am aware of the options to treatment; the associated risks and I have been given the opportunity to ask questions.I agree to be responsible for any associated fees. I certify that I fully understand the terms within the above consent. IVCS Consent I acknowledge that I have read this document Pre-Anaesthesia QuestionnairePatient ID *first 3 letters of your first name and the first 3 letters of your last name:* Date (Please add today's date)* MM slash DD slash YYYY Date of birth:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex:*MaleFemaleOther1. Can you walk up 2 flights of stairs or 2 city blocks quickly without resting?* Yes No Not Sure 2. Do you have any health problems or concerns presently?* Yes No Not Sure Please explain*3. Has there been ANY change in your general health in the past year?* Yes No Not Sure When did you last have a complete physical exam?* How often do you see your family doctor or specialist?* 4. Have you ever been in hospital for treatment?* Yes No When, where and why?* 5. Have you ever had IV Conscious Sedation?* Yes No Not Sure When, where and why?* Were there any problems with the Sedation?* 6. Have you had any problems with IV Conscious Sedation?* Yes No Not Sure Please explain*Were any tests done?* 7. Do you take ANY PRESCRIPTION medications (including puffers and birth control pills)? If yes provide Pharmacy name + number of ALL pharmacies you use.7. Do you take <strong>ANY PRESCRIPTION</strong> medications (including puffers and birth control pills)?* Yes No Name of Pharmacy and Phone Number:* 8. Do you use or take ANY NON-PRESCRIPTION remedies (including herbal remedies)?8. Do you use or take <strong>ANY</strong> non-prescription remedies (including herbal remedies)?* Yes No 9. Are you allergic to any medications?* Yes No Not Sure What Drugs?* What year?* What happened? (Circle) rash breathing problems/wheezing swelling:* 10. Do you have any other allergies (e.g. latex)?* Yes No Other allergies* 11. Do you take any medications for Osteoporosis? ( Bisphosphonates etc. )* Yes No Not Sure Explain :*12. Do you take 81 mg ASA, daily?* Yes No Not Sure 13. Have you taken a cortisone (steroid) type drug orally in the past year?* Yes No Not Sure When? How long were you taking it for?* 14. Do you or any of your relatives have a bleeding problem?* Yes No Not Sure 15. Do you have or have had any difficulty breathing through your nose?* Yes No Not Sure 16. Do you have any nose bleeds?* Yes No Not Sure If so, how many per week?* 17. Do you have or have had any difficulty breathing while sleeping at home?* Yes No Not Sure 18. Do you have or have you ever had any of the following? Heart murmur:* Yes No Not Sure Heart attack:* Yes No Not Sure Chest pain or angina:* Yes No Not Sure Shortness of breath lying down:* Yes No Not Sure Swollen ankles:* Yes No Not Sure Heart pacemaker/defibrillator:* Yes No Not Sure Irregular heart beat/arrhythmia:* Yes No Not Sure High blood pressure:* Yes No Not Sure Shingles:* Yes No Not Sure Congenital heart disease:* Yes No Not Sure Damaged/abnormal heart valves:* Yes No Not Sure Rheumatic fever:* Yes No Not Sure Kidney disease:* Yes No Not Sure HIV, AIDS or STD:* Yes No Not Sure Cancer / Chemotherapy:* Yes No Not Sure Sleep apnea:* Yes No Not Sure Asthma:* Yes No Not Sure Emphysema / Bronchitis:* Yes No Not Sure Cystic fibrosis / Tuberculosis:* Yes No Not Sure Epilepsy:* Yes No Not Sure Stroke:* Yes No Not Sure Fainting spells, dizziness:* Yes No Not Sure Diabetes:* Yes No Not Sure Thyroid Disease:* Yes No Not Sure Adrenal gland disorder:* Yes No Not Sure Hepatitis:* Yes No Not Sure Liver disease / Jaundice:* Yes No Not Sure Anemia (including sickle cell):* Yes No Not Sure Blood disorders/transfusions:* Yes No Not Sure Bleeding (Coagulation) disorders:* Yes No Not Sure Stomach ulcers/ Acid Reflux:* Yes No Not Sure Bone, joint, or muscle problems:* Yes No Not Sure Artificial joints - hips, knees:* Yes No Not Sure Arthritis:* Yes No Not Sure Depression / anxiety:* Yes No Not Sure Vision problems / glaucoma:* Yes No Not Sure Mentally disabled:* Yes No Not Sure Cerebral palsy:* Yes No Not Sure Autism or Down's syndrome:* Yes No Not Sure Are you pregnant?* Yes No Not Sure Are you a nursing mother?* Yes No Not Sure Any problems with menstruation?* Yes No Not Sure 19. Do you ever have episodes of blurred vision or black spots, or experience weakness or paralysis on one side of your body, arms, legs or face?* Yes No Not Sure 20. Do you have any problems opening your mouth wide or moving your neck fully?* Yes No Not Sure 21. Have you ever had surgery, radiation or chemotherapy treatment for a tumour or cancer?* Yes No Not Sure 22. Do you smoke?* Yes No Not Sure If so how much?* 23. Do you drink more than 5 alcoholic beverages per week? Number/week* Yes No Not Sure Number/week* 24. Do you have a history of alcoholism or drug dependence?* Yes No Not Sure 25. Have you taken any recreational drugs in the past year such as marijuana, LSD, PCP, cocaine, crack, crystal meth, codeine, oxycodone or other drugs?* Yes No Not Sure 26. Do you have ANY disease, condition or problem not listed above?* Yes No Not Sure Explain:*What's your weight (lbs)* What's your height?Feet*1234567Inches*1234567891011.5Any additional information you wish to convey to Dr. Kumer please explain below:NameThis field is for validation purposes and should be left unchanged.