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Medical Questionnaire <br /> Fawn Yee"s Permanent Cosmetics <br /> Client Name: <br /> Address: <br /> Phone Numbers: <br /> Health History <br /> YesNo <br /> 1.Are you currently using medication or do you have a history of medication use, including <br /> being prescribed antibiotics prior to dental or surgicalprocedures? <br /> 2. Do you have a history of allergic reactions to latex or antibiotics? <br /> 3.Are you allergic to lanolin? <br /> 4. Do you have a present illness or history of an illness? <br /> 5.Are you presently using any exfoliating agent, such as AHA's,glycolics,or Retin-A? <br /> 6. Do you have any blood disease,e.g. Hepatitis, HIV or AIDS? <br /> 7. Do you have diabetes? <br /> 8. Do you have any healing problems? <br /> 9. Do you have a history of cardiac valve disease or are you taking any heart medication? <br /> 10. Do you have a history of herpes infection at the proposed procedure site? <br /> 11. Do you have a keloid condition? <br /> 12. Do you have a history of hemophilia? <br /> 13.Are you pregnant? <br /> Please provide any clarification if you answered "Yes"to any of the above questions. <br /> Signature: Date: <br /> For Fawn Yee's Permanent Cosmetics Use Only <br />