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Medical Questionnaire (Circle Yes or No) <br /> Are you pregnant or nursing? Yes or No <br /> Is there a history of herpes infection at the procedure site (also known as cold sores)?Yes or No <br /> If yes, explain: <br /> Do you have a history of diabetes, cardiac valve disease, hemophilia or other bleeding <br /> disorders? Yes or No <br /> If yes, explain: <br /> Do you have a history of allergic reactions to latex? Yes or No <br /> If yes, explain: <br /> Do you have a history of allergic reactions to antibiotics?Yes or No <br /> If yes, explain: <br /> Are you taking any medications currently?Yes or No <br /> If yes, explain: <br /> Do you take antibiotics when going to the dentist?Yes or No <br /> If yes, explain: <br /> Do you have any other risk factors for blood borne pathogens?Yes or No <br /> If yes, explain: <br /> The above information is correct to the best of my knowledge: <br /> Client Signature: Date: <br /> Practitioner Signature: Date: <br />