Laserfiche WebLink
SECRET -SIDEWALK TATTOO <br /> MEDICAL HISTORY <br /> NAME: <br /> DATE;OF BIRTH FEMALE E <br /> EMERGENCY CONTACT- <br /> PLEASE <br /> O ACTP E CHECK ANY CONDITIONS THAT APPLY TO YOU <br /> HEPATITIS YES O_ <br /> HIV/AIDS ®NO- <br /> D _N0 <br /> BLOOD THINNERS O_ <br /> FAINTING OR DIZZINESS YES N0- <br /> T.B YES_NO__ <br /> ASTHAMA YES NO <br /> ALLERGIC REACTION TO LATEX YES.- <br /> NO-ALLERGIC REACTION TO ANTIBIOTICS YES- O_ <br /> ECZEMA-PSORIASIS O_ <br /> SIGN CONDITION., YE I S__NO- <br /> HISTORY OF CARDIAC VALVE DISEASE YES NO_ <br /> HEART CONDITION __ O® <br /> HEMOPHILIA YES NO_ <br /> ES . NO <br /> EPILEPSY/SEIZURE DISORDER _NO_ <br /> S RING-KELOIDING YES NO . <br /> PREGNANCY-NURSING YES_NO_ <br /> DO YOU NEER TO BE-PRE-MEDICAt8D PRIOR TO SUR G- ERY.OR DENTAL <br /> PROCEDURE? YES_NO_ <br /> OTHER <br /> IF YOU .. D TO . ., •OF THE O ,PLEASE <br /> , <br /> Ei�_ N _ _ <br /> LIST OF CURRENT <br /> MEDICATIONS <br /> HOW LONG HAS IT BEEN SINCE YOU ATE T? <br /> HAVE YOU SLEPT AT.LEAST 5 HOURS LAST NIGHT OR TODAY? <br /> ITS <br />