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MEDICAL HISTORYQUESTIONNAIRE <br /> Name: <br /> Last First Middle <br /> Date of Birth: Sex: <br /> Address: <br /> Emergency Contact: Phone: <br /> Please check any condilions listed below that apply to you. <br /> ALLERGIC TO ANTIBIOTICS EPILEPSY HERPES <br /> ALLERGIC TO LATEX FAINTING OR DIZZINESS HIV <br /> ASTHMA GONOR RHEA°'SYPHILIS MRSASTAPH INFECTION <br /> BLOOD THINNERS HEART CONDITION PREGNANTr'NURSING <br /> DIABETES HEMOPHILIA SCARRINGOIDING <br /> ECZEMAYPSORIASIS HEPATITIS SKIN CONDITIONS <br /> OTHER* <br /> If you checked other,please state the condition. <br /> How long has it been since you last ate? <br /> Do you have any allergies such as metals, soaps,cosmetics or alcohol? <br /> Do you use any medications that might affect the heating of the body art you wish to receive? <br /> Do you have any other medical or skin conditions that may affect the outcome of your procedure? <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? <br /> Do you have any cardiac valve disease? <br /> Is there any other information you feel you should provide to the body art practitioner? <br /> The information I have provided is complete and true to the best of my knowledge. <br /> Signature of Client: Date: <br />