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0 0 <br /> Medical Histo Continued (page 2 of 2 <br /> History �p 9 ) <br /> Do you have or have you had any of the following conditions? (Circle one) <br /> Yes No Abnormal Heart Condition <br /> Yes No High or Low Blood Pressure <br /> Yes No History of cardiac valve disease <br /> Yes No Herpes Simplex (any history, no matter how many years ago, specifically at <br /> procedure site) including cold sores and fever blisters <br /> Yes No Hemophilia or other blood disorders <br /> Yes No Prolonged Bleeding <br /> Yes No Circulatory Problems <br /> Yes No Diabetes <br /> Yes No Cataracts <br /> Yes No "Dry Eye" <br /> Yes No Eye Surgery or Injury <br /> Yes No Visual Disturbances <br /> Yes No Tumors/Growths/Cysts <br /> Yes No Epilepsy <br /> Yes No Fainting spells/dizziness <br /> Yes No Glaucoma <br /> Yes No Corneal Abrasion <br /> Yes No Blepharoplasty <br /> Yes No Cancer <br /> Yes No Chemotherapy/Radiation <br /> Yes No Hepatitis <br /> Yes No A Pacemaker or major heart problems <br /> Yes No Collagen Vascular Disease <br /> Yes No Auto-immune Disease (Lupus/Rheumatoid Arthritis) <br /> Yes No Are you pregnant? <br /> Yes No History of allergic reactions to latex <br /> Yes No History of allergic reaction to antibiotics <br /> Yes No Do you use tobacco products? <br /> Yes No Do you drink alcohol? <br /> Yes No Do you require antibiotics prior to surgery or dental procedures? <br /> Yes No Any risk factors for blood borne pathogens? <br /> Yes No Are you using any eye drops or other ocular medications? <br /> Yes No Have you ever experienced hyper-pigmentation from an injury? <br /> Yes No Have you ever keyloided from a injury? <br /> Yes No Are you currently taking aspirin or ibuprofen? <br /> When was your last eye exam? _/_/_ Examining Physician's Name <br /> Print Name Date <br /> Signature <br />