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Medical History Questionnaire <br />Have you had or currently have any of the following? <br />Yes <br />`, No _! <br />Currently Pregnant - <br />- r <br />r - <br />Currently Breastfeeding - _ <br />r <br />Had history of Methicillin-resistant Staphylococcus ameus.(tyMA) <br />Had undergone Bates, treatment <br />Has oi- any family history of Diabetes <br />Has Hepatitis AB C D <br />s '' <br />Had Forclread/BrowLift - <br />r <br />Had FaceliffSurgery - - <br />r <br />'r <br />Has a Heart Condition - - <br />` t` <br />Has Autoittnnune-disorder <br />- <br />d` <br />His, hid, of any family history of having Cancer <br />f'd. <br />Had undergone Chemotherapy/ Radiation <br />w <br />i <br />Taking or have taken none treatments in the past 3 months <br />r` <br />I -tad a Tan treatment. - <br />r <br />Difficulty numbing with dental work <br />Taking blood -thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin <br />etc r <br />f <br />Allergic reaction to any medications _ <br />�' <br />C <br />Allergies to metals, food, etc., <br />r'- <br />fr <br />Do you use facial care treatments? - <br />f' <br />History of herpes infection at the procedure site? <br />- r <br />{` <br />