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Client Name Date <br /> QUESTIONNAIRE <br /> Please check any conditions listed below that apply to you. <br /> Diabetes Hemophilia T.B Asthma <br /> Epilepsy Blood thinners Eczema/Psoriasis Allergic reactions to latex <br /> Fainting or Dizziness Herpes(at the Scarring/Keloiding Allergic reaction to antibiotics <br /> procedure site) <br /> Cardiac valve disease Pregnant/Nursing Skin Conditions Other <br /> History of hemophilia or other bleeding disorders? <br /> Other risk factors for bloode borne pathogens? <br /> How long has it been since you last ate? <br /> Do you have any allergies? <br /> Do you use any medications that might affect the healing of the body art you wish to receive? <br /> Do you have any other medical or skin conditions that may affect the outcome of your procedure? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Is there any other information you feel you should provide to the body art practitioner? <br />