Laserfiche WebLink
Medical History Continued (page 2oQ) <br /> Do you have or have you had any of the following conditions? (Circle one) <br /> Yes No Abnormal Heart Condition <br /> Yes No A Pacemaker or major heart problems <br /> Yes No History of cardiac valve disease <br /> Yes No High or Low Blood Pressure <br /> Yes No Herpes Simplex at the procedure site <br /> Yes No Hemophilia <br /> Yes No Prolonged Bleeding <br /> Yes No Circulatory Problems <br /> Yes No Diabetes <br /> Yes No Tumors/Growths/Cysts <br /> Yes No Epilepsy <br /> Yes No Cancer <br /> Yes No Chemotherapy/Radiation <br /> Yes No Auto-immune Disease (Lupus/Rheumatoid Arthritis) <br /> Yes No Collagen Vascular Disease <br /> Yes No Hepatitis <br /> Yes No Fainting spells/dizziness <br /> Yes No Are you pregnant? <br /> Yes No Have you ever experienced hyper-pigmentation from an injury? <br /> Yes No Have you ever keloided from a injury? <br /> Yes No history of allergic reactions to latex <br /> Yes No requirements for antibiotics prior to surgery or dental procedures <br /> Yes No history of allergic reactions to antibotics <br /> Yes No currently taking aspirin or ibuprofen? <br /> Yes No drank alcohol in the last 24 hours? <br /> Yes No use tobacco products? <br /> es No Any other risk factors for blood borne pathogens <br /> Print Name Date <br /> S' a t,1 re <br /> ZI - <br />