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MEDICAL QUESTIONIRE <br />(Y/ N) Alle -gic reaction to latex <br />(Y/ N) Alle -gic reaction to ar-tibiotics <br />(Y/ N) HistDry of hemophilia or other bleeding disease <br />(Y/ N) Hist Dry of cardiac valve disease <br />(Y/ N)Requirements "'or antibiotics prior to dental or surgery procedures <br />(Y/ N)Other risk factors for blood borne pathogen <br />AFTERCARE INSTRUCTIONS <br />CLIENT NAME: <br />The followi-ig verbal aid/or written instructions were communicated to the client: <br />1. Informat on on the care of the procedure site. <br />2. Restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with <br />animals, and the duration of the restrictions. <br />3. Signs and symptoms of in-ection including but not limited to redness, swelling, tenderness of the procedure <br />site, red streaks going from tie procedure site towards the heart, elevated body temperature, or purulert <br />drainage fr,Dm the procedure site. <br />4. Instructions to call a physi -ian if any of the addressed signs and symptoms appear or for any other reason <br />related to the Body Art procedure(s). <br />5. If physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body <br />Art facility and practit cner of the problem and the resolution by a physician or clinic. This information sh 311 be <br />placed in tl-e client's 1lie. <br />6. Clean area serval times a day, wash hands before applying ointment A&D or Aquaphor. <br />To the best of my kncwledge this information is correct: <br />Practitioner SignaturE: Date: <br />I have rece ved aftercare instructions: <br />Client Signature: Date: <br />