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Medical History Questionnaire <br />Please check any conditions listed below that apply to you <br />Diabetes <br />Hemophilia or <br />T.B <br />Allergic reaction to <br />other bleeding <br />latex <br />disorders <br />Epilepsy <br />Blood Thinners <br />Scarring/Keloids <br />Allergic reaction to <br />Antibiotics <br />Fainting or Dizziness <br />Herpes infection <br />Asthma <br />Eczema/psoriasis <br />at/on the <br />procedure site <br />Heart Condition/ <br />Pregnancy/ <br />Skin Conditions <br />Other: <br />Cardiac Valve Disease <br />Nursing <br />Other risk factors for <br />bloodborne pathogens <br />How long has it been since you last ate? <br />Do you have any allergies? <br />Do you use any medications that can affect the healing of the body art you wish to receive? <br />Do you have any medical or skin conditions that may affect the outcome of your procedure? <br />Are you currently prescribed to any antibiotics or blood thinners? <br />Is there any other information that you feel you should provide to the body art practitioner? <br />The information I have provided above is complete and true to the best of n¢y knowledge <br />Signature: Date: <br />