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DICAL STORY QUESTIONN __ <br /> Name: Middle <br /> Last First <br /> Date of Birth: Sex: <br /> Address: <br /> Emergency Contact: Phone: <br /> Please check any conditions listed below that apply to you. <br /> Diabetes Hemophilia T•$ <br /> Asthma <br /> Epilepsy Blood Thinners Eczema/Psoriasis Allergic reactions to <br /> latex <br /> Fainting or history of herpes Scarring/Keloiding Allergic reaction to <br /> Dizziness <br /> infection at the antibiotics <br /> procedure site <br /> Pregnancy/ Skin Conditions other risk factors for <br /> history of cardiac blood borne pathogens <br /> valve disease Nursing <br /> How long has it been since you last ate? <br /> Do you have any allergies? <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 /> Is there any other information you feet you should provide to the body art practitioner? <br /> lete and true to the best of my knowledge. <br /> The information I have provided is comp <br /> Signature of Client: <br /> Date: <br />