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Medical History Questionnaire <br />Have you had or currently have any of the following? <br />Yes No <br />Currently Pregnant rC <br />Currently Breastfeeding <br />Had history of Methicillin-resistant Staphylococcus aureus (MRSA) r i'. j <br />Had undergone IIotox treatment �' � <br />Hes or any family history of Diabetes <br />Had undergone Chemotherapy/ Radiation I, r <br />. � <br />� <br />Has Hepatitis A B C D <br />r <br />Had Forehead/Brow Lift <br />r <br />Had Facelift Surgery <br />f' <br />Has a Heart Condition <br />r. <br />I <br />r <br />HasAutoimmunedisorder <br />r' <br />r <br />Hes, had, or any family history of having Cancer <br />{'' <br />C <br />Taking or have taken acne treatments in the past 3 months - C r" - <br />Had a Tan treatment f'' r <br />Difficulty numbing with dental work <br />i <br />Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc f" r <br />Allergic reaction to any medications <br />Allergies to metals, food, etc, r i <br />