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1VIEDICAL ffiSTORY QUESTIONNAIRE <br /> ivaitae, <br /> Last <br /> First Middle <br /> Date c,� Birth: <br /> Sex: <br /> ,address: <br /> Emergency Contact: Phone: L__) <br /> Please check any conditions listed below that apply to you. <br /> Di abetes Hemophilia T.B <br /> 7Epilepsy <br /> j Flood Thinners Eczema/Psoriasis actions to <br /> Fainting or history of herpes Scarring/Keloiding Allergic maction to <br /> Dizziness injection at the antibiotics <br /> procedure site <br /> hisbry of cardiac P-egnancy/ Skin Conditions other risk factors for <br /> val-e disease Nursing blood borne pa:hogens <br /> How long has it been since you las:ate? <br /> Do you have any allergies: <br /> Do you use any medications that night affect the healing 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 /> FF-ve you ever peen prescri led antibiotics prior to dental or surgical procedures? <br /> (s there any other informaticn you feel you should provide to the body art practitioner? <br /> Are you or :'lave you been sick with any symptoms related to covid-19:' <br /> Lady temperature time <br /> The info/ptado/L I have provided is eomplete and true to the best of my knowledge. <br /> mature of Client;. Date: <br /> 1-� <br /> : r <br />