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Medical Questionnaire <br /> Fawn Yee's Permanent Cosmetics <br /> Client Name: <br /> Address: <br /> Phone Numbers: <br /> Health History <br /> Yes No <br /> 1.Are you currently using medication? <br /> 2. Have you been prescribed antibiotics prior to dental or surgical procedures? <br /> 3. Do you have a history of allergic reactions to latex? <br /> 4. Do you have a history of allergic reactions to antibiotics? <br /> 5.Are you allergic to lanolin? <br /> 6.Are you currently ill? <br /> 7. Do have a history of an illness? <br /> 8.Are you presently using any exfoliating agent,such as AHA's,glycolics,or Retin-A? <br /> 9. Do you have any blood disease,e.g. Hepatitis, HIV or AIDS? <br /> 10. Do you have diabetes? <br /> 11. Do you have any healing problems? <br /> 12. Do you have a history of cardiac valve disease? <br /> 13.Are you currently taking any heart medication? <br /> 14. Do you have a history of herpes infection at the proposed procedure site? <br /> 15. Do you have a keloid condition? <br /> 16. Do you have a history of hemophilia or other bleeding disorders? <br /> 17. Do you have other risk factors for blood borne pathogens? <br /> 18.Are you pregnant? <br /> If you answered "Yes"to any of the above questions, please provide clarifications below. <br /> Signature: Date: <br /> For Fawn Yee's Permanent Cosmetics Use Only <br />