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MEDICAL IRSTORY <br /> Please check any conditions listed to thatapply to you. <br /> Diabetes Hemophilia _ _ I T.B Asthma <br /> Epilepsy Blood Thinners Eczema/Psoriasis Acte is reactions to <br /> latex <br /> Fainting or Herpes ScarringtKeloiding Allergic reaction to <br /> Dizziness antibiotics <br /> Heart Condition Pregnant/ Skin Conditions Other <br /> Nurs inev <br /> How long has it been since you las: <br /> .1 ate? <br /> Do you have any allergies? <br /> Do you use any medications that might affect the healing of the body art you Vvish to receive? <br /> Do you have any other medical-%-Jr skin conditions that may affect the outcom e of your procedure? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Is there any other information you feet you should provide to the body art practitioner? <br /> Permanent Cosmetics and Tattooing Page 2 of 3 <br />