Laserfiche WebLink
Sharon Cruz Wiried Microfflade Artist LA 612-0430 <br /> Medical History Form <br /> Today's Date: / / Birth date: <br /> Name: <br /> Home Address: <br /> No.&Street City State Zip <br /> Work Address: <br /> No.&Street City State Zip <br /> Home Phone: ( ) Work Phone: <br /> Employer: Occupation: <br /> Are you now or have you been under the care of a physician within the last two years? <br /> If yes,please provide Physician's Name, address and phone number. <br /> Person to contact in an emergency: <br /> Name <br /> Address&Phone No. <br /> List all medications you are currently taking,including Retin A,Glycolic Acid,and Acutane: <br /> List any drug,makeup,skin or food allergies (i.e.latex,soap or antibiotics: <br /> Have you recently undergone a skin peel. <br /> What products do you use for skin care? <br /> Do you have or have you had any of the following conditions (answer Yes or No): <br /> Abnormal Heart Condition? Eye Surgery or Injury? <br /> Cold Sores? Blepharoplasty(Eyelid Surgery)? <br /> Herpes Simplex? Visual Disturbances? <br /> Hemophilia? Cancer? <br /> High or Low Blood Pressure? Tumors/Growths/Cysts? <br /> Prolonged Bleeding? Chemotherapy/Radiation? <br /> Circulatory Problems? Are You Pregnant? <br /> Epilepsy? Hepatitis? <br /> Diabetes? Do you wear Contact Lenses? <br /> Fainting Spells/Dizziness? Keloid Condition? <br /> Cataracts? Cardiac Valve Disease? <br /> Glaucoma? Eye Drops of Ocular Medications? <br /> "Dry Eye"? Hyper-pigmentation? <br /> Corneal Abrasions? Currently taking Aspirin or Ibuprofen? <br /> History of herpes infection at the procedure site? History of hemophilia or other bleeding disorders? <br /> History of allergic reactions to antibiotic? Other risk factors for bloodborne pathogens? <br /> History of allergic reaction to latex? Requirements for antibiotics prior to surgery or <br /> dental procedures? <br /> When was your last eye exam? <br /> Examining Physician: <br /> Signature Date <br /> Page 5 of 8 <br />