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Client Medical al IH istory Form <br /> Name Birthdate <br /> Address <br /> Phone Email <br /> Emergency Contact Person Phone <br /> Do you have or previously had any of the following; (Cirlce YES or No) <br /> YENO Are or could you be pregnant? <br /> YES NO Are you breastfeeding? <br /> YES NO History of MRSA? <br /> YES NO Botox (Last treatment ) <br /> YES NO Diabetes ? <br /> YES NO History of Hemophilia or bleeding disorder? <br /> J <br /> YES NO History of Cardiac Valve Disease? <br /> YES NO Hepatitis A B C D ? <br /> YES NO Forehead/Brow Lift? <br /> YES NO Easy Bleeding? <br /> YES NO Facelift? <br /> YES NO Alcoholism? <br /> YES NO Abnormal Heart Condition? <br /> YES NO Take medication before dental work? <br /> YES NO Chemical Peel (Last Treatment <br /> YES NO Brow Lash Tinting ? <br /> YES NO Autoimmune disorder? <br /> YES NO Oily Skin? <br /> YES NO Cancer (Year ) ? <br />