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U <br /> Adva heed Gsf e-fi cs <br /> Permanent Makeup <br /> Client Name: <br /> Address: <br /> Phone Number/s: <br /> HEALTH HISTORY <br /> Yes No <br /> 1. Are you taking any preecription or over-the-counter medicatidns? <br /> 2. Are you allergic to any medications? <br /> 3. Are you allergic to lanolin? <br /> 4. ' Do you have a preeent illness or a history of an illness? <br /> 5. Are you yresently using any exfoliating agents,such as AHA's,glycolics,or Retin-A? <br /> 6. Do you have any blood disease,e.g., Hepatitis, HIV or A105? <br /> 7. Do you have diabetes? <br /> 8. Do you have any healing roblems? <br /> 9. Do you have a heart condition or are you taking heart medication? <br /> 10. Have you ever had a cold sore on your lips? <br /> 11. Do you have a keloid condition? <br /> Please provide clarification if you anowered"Yes"to any of the above questions. <br /> For Advanced Estketics Use Only <br /> Page 1 of 2 <br /> s <br />