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MI " Anchors Away Tattoo <br /> Root ca 9S249209 E Kettleman Ln <br /> � � . <br /> SEXA HAM <br /> HT:6 WT:1 6 4 Lodi Ca 95240 <br /> 209-339-8288 <br /> 0324!2010 621 V FD/IS <br /> Medical Himstory Questionnaire <br /> CHECK ANY CONDITIONS BELOW THAT APPLY TO YOU <br /> Diabetes Hepatitis Pregnancy/nursing <br /> Hemophilia Dizziness czema/Psoriasis <br /> T.B. Fainting Scarring/Keloiding <br /> Epilepsy Herpes History of cardiac valve disease <br /> IV Skin conditions Allergic to Latex <br /> Allergic Reaction to Antibiotics Other <br /> How long has it been since you last ate? <br /> Do you have any allergies? Y / <br /> If yes please explain: <br /> Do you use any medications that might affect the healing of your procedure? Y / N <br /> If yes please explain: <br /> Do you have any other medical or skin conditions that might affect the outcome of <br /> your procedure? Y / <br /> If yes please explain: <br /> Have you ever been prescribed antibiotics prior to dental or surgical procedures? Y / <br /> If yes please explain: <br /> Is there any other information you feel you should provide to the artist? Y/ <br /> If yes please explain: <br /> BY SIGNING IM SAYINGTHAT I HAVE PROVIDED ON THIS COMPLETE TRUTH TO <br /> THE REST OF MY KNOWLEDGE. <br /> SIGNATURE: ATE: / / <br />