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MEDICAL HISTORY QUESTIONNAIRE <br /> Name: <br /> Last First Middle <br /> Emergency Contact: Phone: ( ) <br /> Please circle any conditions listed below that apply to you. <br /> TB EPILEPSY BLOOD THINNERS SCARRING/KELOIDING <br /> HIV ASTHMA ECZEMA/PSORIASIS GONORRHEA/SYPHILIS <br /> HEPATITIS HEART CONDITION MRSA/STAPH INFECTIONS <br /> HERPES HEMOPHILIA/OTHER PREGNANT/NURSING ALLERGIC REACTIONS TO LATEX <br /> BLEEDING DISORDER <br /> DIABETES SKIN CONDITIONS FAINTING OR DIZZINESS ALLERGIC REACTIONS TO ANTIBIOTICS <br /> Flow tong has it been since you last ate? <br /> Do you have any additional allergies such as to metals, soaps, cosmetics or alcohol? <br /> Do you use any medications that might affect the healing of the body art you wish to receive? <br /> Do you have a history of herpes at the procedure site? <br /> Do you have any other medical or skin conditions that affect the outcome of your procedure? <br /> Lave you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Do you have any cardiac valve disease? <br /> is there any information you feel you should provide to the body art practitioner? <br /> Other medical conditions? <br /> The information I have provided is complete and true to the best of my knowledge. <br /> :Signature of Client: Date: <br /> Signature of Practitioner: Date: <br />