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9 0 <br /> MEDICAL HISTORY QUESTIONNAIRE <br /> In order to best serve your medical needs,we ask thatyou complete the following questionnaire. By completing and <br /> signing this form,you acknowledge and understand any intentionally false information may seriously and adversely <br /> affectyour health. <br /> Client Name: <br /> Last First Middle <br /> Date of Birth (MM/DD/YYYY) Gender: <br /> Address: <br /> Emergency Contact Name: Phone: ( ) <br /> Mhy <br /> Please check,cl" conditions below that may apply to you. <br /> Yes No �� ��Condition Yes No Condition Yes No Condition Yes No Condition <br /> Diabetes T.B. Psoriasis Skin Condition <br /> Epilepsy Herpes Simplex Scarring Pregnant <br /> Heart Condition Cold Sores Prone to Keloids Nursing <br /> Cardiac Valve Hepatitis Latex Allergy Asthma <br /> Hemophilia HIV Lanolin Allergy Wear Contacts <br /> Bleeding Disorder AIDS Fainting Eine Allerpv <br /> On Blood Thinner Eczema Dizziness <br /> Are you taking any over-the-counter or prescription medications? If so,please list and explain what <br /> each one is for: <br /> Are you allergic to any medications and/or antibiotics? If so,please list: <br /> Do you have any allergies? If yes,please explain: <br /> Do you require antibiotics prior to surgery or dental Procedures? <br /> Do you have an illness or present history of illnesses? If yes,please explain: <br /> Are you using any exfoliating agent(i.e.,AHA, Retina,Glycolic)? <br /> Do you have any medical/skin conditions or are you taking any medications that may affect the outcome of this <br /> procedure? If Yes,please explain: <br /> Is there any other information you feel would benefit your procedure that you should provide to your body art <br /> practitioner? <br /> As evidence by the signature below, I claim to be the above stated person and have answered the questions honestly to <br /> assist in my permanent cosmetic tattooing. <br /> Client Signature: Date: <br />