Laserfiche WebLink
MEDICAL HISTORY <br />Please circle Yes or No for any conditions listed below that apply to you. <br />Y/N <br />Diabetes <br />Y/N <br />Hemophilia <br />Y/N <br />Pregnant/ <br />Y/N <br />Skin Conditions <br />Nursing <br />Y/N <br />Epilepsy <br />Y/N <br />Blood <br />Y/N <br />T.B. <br />Y/N <br />Asthma <br />Thinners <br />Y/N <br />Fainting or <br />Y/N <br />Herpes <br />Y/N <br />Eczema / <br />Y/N <br />Allergic reactions to <br />Dizziness <br />(location of <br />Psoriasis <br />latex <br />permanent <br />ink <br />Y/N <br />Heart <br />Y/N <br />HIV/AIDS <br />Y/N <br />Scarring / <br />Y/N <br />Allergic reactions to <br />Condition <br />Keloiding <br />antibiotics <br />Do you have a Cardiac Valve Disease? <br />How long has 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 <br />receive? <br />Do you have any other medical or skin conditions that may affect the outcome of your <br />procedure? <br />Are there any other risk factors for bloodborne pathogens that the body art practitioner <br />needs to be aware of? <br />Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br />Is there any other information you feel that you should provide to the body art <br />practitioner? <br />Permanent Cosmetics and Tattooing Page 2 of 3 <br />