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MEDICAL HISTORY QUESTIONNAIRE <br /> Name: <br /> Last First Middle <br /> Date of Birth: Sex: <br /> Address: <br /> Emergency Contact: Phone: <br /> Please check any conditions listed below that apply to you. <br /> I Diabetes Hemophilia T.B Asthma <br /> Epilepsy Blood Thinners Eczema/Psoriasis Allergic reactions to <br /> latex <br /> Fainting or Herpes ScarringiKeloiding Allergic reaction to <br /> Dizziness antibiotics <br /> Heart Condition Pregnancy/ Skin Conditions Other: <br /> Nursing I <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 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 /> 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 /> The information I have provided is complete and true to the best of my knowledge. <br /> Signature of Client: Date: <br />