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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 />C - <br />Cnri•eutly Breastfeeding - - <br />- 1` <br />i_- <br />Had history of Metbicillin-resistant Staphylococcus omens (MRSA) - <br />r <br />:. r <br />Had undergone Botox- treatment - <br />?' <br />C, <br />Has or any family history of Diabetes <br />N <br />Has Hepatitis A C D <br />{� <br />Had Fo dread/Brow Lift - - - - <br />i <br />i•` <br />- Had Facelift Surgery <br />C <br />r <br />Hasa Hour Condition <br />Has Autoinimunc disorder <br />Has, had, or any family history of having Cancer <br />C <br />r <br />Had undergone Chemotherapy/ Radiation <br />Taking or -have -taken acne treatments in the past 3. months <br />C <br />Had. a Tan treatment - - <br />'r, <br />- r•' <br />Difficulty numbing with dental work <br />r <br />f <br />- Taking blood thinners such as: Aspirin, Ibuprofen, Alcohol, Coumadin etc. <br />Allergic reaction to any medications <br />r <br />r - <br />