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MEDICAL HISTORY PORTION <br />Have you been under the care of a physician within the last two years? . <br />Person to contact in an emergency: ______________________________________ <br />List all medications you are currently taking, including Retin A, Glycolic Acid and <br />Acutane:___________________________________________________________ <br />Any history of antibiotics prescribed prior to dental or surgical procedures? If so, <br />what? ____________________________________________________________ <br />List any drug, makeup, skin or food allergies (i.e., latex, soaps or antibiotics): <br />__________________________________________________________________ <br />Have you recently undergone a skin peel? ________________________________ <br />What products do you use for skin care?__________________________________ <br />Any other risk factors for blood borne pathogen exposure? ___________________ <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 (at procedure site) ______Visual Disturbances. <br />______Hemophilia (or other bleeding disorders) ______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/ocular medications? <br />______“Dry Eye” ______Hyper-pigmentation? <br />______Corneal abrasions ______Recently used aspirin/ ibuprofen? <br />Last eye exam? / / Examining Physician:______________________ <br />Signature __________________________________ Date _____________