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0 <br /> Client Name Date <br /> QUESTIONNAIRE <br /> Please check anyconditions listed below that a to you. <br /> Diabetes Hemophilia T.B Asthma <br /> Evil2psy Blood thinners, Eczema/Psoriasis Alle!]gic reactions to latex <br /> Fainting or Dizziness Herpes(at the Scarring/Keloiding Allergic reaction to antibiotics <br /> Eocedure site <br /> I Cardiac valve disease Pregnant/Nursing Sldn Conditions Other <br /> History of hemophilia or other bleeding disorders? <br /> Other risk factors for blood borne pathogens? <br /> How long has it been since you last ate? <br /> Do you have any allergies? <br /> Do you use any current medications? <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 /> Is there any other information you feel you should provide to the body art practitioner? <br /> Signature <br />