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Email <br />example@example.com <br />Medical History Questionnaire <br />Have you had or currently have any of the following <br />®� No <br />Yes <br />No <br />Currently Pregnant <br />0 <br />0 <br />Currently Breastfeeding <br />0 <br />0 <br />Had history of Methicillin-resistant Staphylococcus aureus (MRSA) <br />0 <br />0 <br />Had undergone Botox treatment <br />0 <br />0 <br />Has or any family history of Diabetes <br />0 <br />0 <br />Has Hepatitis A B C D <br />0 <br />0 <br />Had Forehead/Brow Lift <br />0 <br />0 -, <br />Had Facelift Surgery <br />0 <br />0 <br />Has a Heart Condition <br />0 <br />0 <br />Has Autoimmune disorder <br />0 <br />0 <br />Has, had, or any family history of having Cancer <br />0 <br />0 <br />Had undergone Chemotherapy/ Radiation <br />0 <br />0 <br />Taking or have taken acne treatments in the past 3 months <br />0 <br />0 <br />Had a Tan treatment <br />0 <br />0 <br />Difficulty numbing with dental work <br />0., <br />0 <br />Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc <br />0 <br />0 <br />Allergic reaction to any medications <br />0 <br />0 <br />Allergies to metals, food, etc, <br />0 <br />1 0 <br />Do you use facial care treatments? <br />0 <br />I,. 0 <br />History of herpes? <br />0 <br />I, 0 <br />History of allergic reactions to latex? <br />0 <br />0 <br />History of allergic reactions to antibiotics? <br />0 <br />0 <br />w aoale your omen Jolfonn -It's free! CreidO yOrn' Own JOtfOrnl <br />