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10DICAL QUESTIONNAIP6 <br /> Please check any conditions listed below that apply to you <br /> • Diabetes Epilepsy • Hemophilia • Blood Thinners • Fainting or Dizziness <br /> • Herpes • Asthma •Tuberculosis • Cardiac Valve Disease • Eczema/Psoriasis <br /> • Pregnant and/or Nursing • Allergic reactions to antibiotics • Scarring/Keloiding <br /> • Allergic reactions to latex • Skin Conditions Please explain: <br /> • Other risk factors for bloodborne pathogen exposure Please explain: <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> How long has it been since you last ate? <br /> Do you have any allergies? <br /> y7 $ r D <br /> Do you use any medications that migttct tf� Baling of the bodk o receive? <br /> NNN <br /> � u <br /> Do you have any other medical skin conditionshi � �' tcome rprocedure? <br /> c <br /> NN <br /> X11 ,.,r�� 4��r 1����� <br /> Is there any other info. r pt n you feel you�shop td proy t h ody art ioner? <br /> fi (M 9,A1 'IIo ­ <br /> A-0 <br /> E FOI: > tG; EIS TOE FILL d BYE (1R <br /> w NESMR <br /> gwog <br /> ANIMUS. <br /> " �S. <br /> :� �,ky2� <br /> INK BRAND(S) A1 � tt(S� r rix <br /> I <br /> `K11 c <br /> m i qI <br /> ar K <br /> 1 � <br /> 'Mg c� <br /> CLIENT IDENTIFICATION <br />