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MEDICAL HISTORY <br /> Please circle Yes or No for any conditions listed below that apply to you. <br /> Y/N Diabetes Y/N Hemophilia Y/N Pregnant/ Y/N Skin Conditions <br /> Nursing <br /> Y/N Epilepsy Y/N Blood Y/N T.B. Y/N Asthma <br /> Thinners <br /> Y/N Fainting or Y/N Herpes Y/N Eczema / Y/N Allergic reactions to <br /> Dizziness (location of Psoriasis latex <br /> permanent <br /> ink <br /> Y/N Heart Y/N HIV/AIDS Y/N Scarring / Y/N Allergic reactions to <br /> Condition Keloiding antibiotics <br /> Do you have a Cardiac Valve Disease? <br /> How long has been since you last ate? <br /> Do you have any allergies? <br /> Do you use any medications that might affect the healing of the body art you wish to <br /> receive? <br /> Do you have any other medical or skin conditions that may affect the outcome of your <br /> procedure? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Is there any other information you feel that you should provide to the body art <br /> practitioner? <br /> Permanent Cosmetics and Tattooing Page 2 of 3 <br />