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1. Are you taking any prescription or over the counter medication? Y/N <br /> 2. Are you allergic to any medications? Y/N <br /> 3. Do you have any present illness or history of illness? Y/N <br /> 4, Are you presently using an embliating such as ANA or Retro-A or collagen? Y/N <br /> 5. Do you have any blood disease such as Hepatitis,HIV or AIDS Y/N <br /> 6. Do you have diabetes,how is it being treated? Y/N <br /> 7. Do you having any healing problems? YIN <br /> 8. Do you have a heart condition and are you take medication? Y/N <br /> 9. Have you ever had a cold sore? Y/N <br /> 10. Do you have keloid condition? YIN <br /> 11. Do you have cancer? YIN <br /> 12.Are you pregnant or nursing? Y/N <br /> Please provide any clarification if you answer yes to any of these question: <br /> Comments related to health history questionnaire: <br /> I hereby declare that i am of legal age,have provided valid proof of age,and I am competent to <br /> sign this. <br /> I have read this agreement, I understand it, and I agree to be bound by it. <br /> Print Full Name: Date of birth: <br /> Address: Telephone: <br /> E-mail: Date: Total: <br />