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Medical History Continued (page2of2) Do you have or have you had any of the following conditions? (Circle one) Yes No Abnormal Heart Condition Yes No A Pacemaker or major heart problems Yes No History of cardiac valve disease Yes No High or Low Blood Pressure Yes No Herpes Simplex at the procedure site Yes No Hemophilia Yes No Prolonged Bleeding Yes No Circulatory Problems Yes No Diabetes Yes No Tumors/Growths/Cysts Yes No Epilepsy Yes No Cancer Yes No Chemotherapy/Radiation Yes No Auto -immune Disease (Lupus/Rheumatoid Arthritis) Yes No Collagen Vascular Disease Yes No Hepatitis Yes No Fainting spells/dizziness Yes No Are you pregnant? Yes No Have you ever experienced hyper -pigmentation from an injury? Yes No Have you ever keloided from a injury? Yes No history of allergic reactions to latex Yes No requirements for antibiotics prior to surgery or dental procedures Yes No history of allergic reactions to antibotics Yes No currently taking aspirin or ibuprofen? Yes No drank alcohol in the last 24 hours? Yes No use tobacco products? Yes No Any other risk factors for blood borne pathogens Print Name Signature Date