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MEDICAL HISTORY <br /> PLEASE CIRCLE ANY CONDITIONS LISTED BELOW THAT <br /> APPLY TO YOU, <br /> TB EPILEPSY BLOOD THINNERS SCARRING/KELOIDING <br /> HIV ASTHMA ECZEMA/PSORIASIS GONORRHEA/SYPHILIS <br /> HEPATITIS HEART CONDITION MRSA/STAPH INFECTIONS HERPES <br /> HEMOPHILWOTHER BLEEDING DISORDER PREGNANT/NURSING <br /> ALLERGIC REACTIONS TO LATEX DIABETES SKIN CONDITIONS <br /> FAINTING OR DIZZINESS ALLERGIC REACTIONS TO ANTIBIOTICS <br /> OTHER RISK FACTORS FOR BLOODBORNE PATHOGENS <br /> INFECTION AT THE PROCEDURE SITE <br />