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Do you have or have you had any of the following conditions (and Yes or No and initial <br /> all): <br /> Abnormal Heart Condition Glaucoma <br /> Are you Pregnant? "Dry Eye" <br /> Herpes Simplex Corneal Abrasions <br /> (at procedure site) Eye Surgery or Injury <br /> Hemophilia Blepharoplasty(Eyelid <br /> or other Bleeding Disorders Surgery) <br /> High or Low Blood Pressure Visual Disturbance <br /> Prolonged Bleeding Cancer <br /> Circulatory Problems Tumors/ Growths/ Cysts <br /> Epilepsy Chemotherapy/Radiation <br /> Diabetes Had cold sores? <br /> Fainting Spells/ Dizziness Hepatitis <br /> Cataracts Do you wear contact <br /> Other risk factors for blood lenses? <br /> Borne pathogens Do you use tobacco <br /> Products? <br /> Have you ever experienced hyper pigmentation from an injury? <br /> Are you currently taking aspirin or ibuprofen? <br /> Signature Date <br />