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CLIENT MEDICAL HEALTH FORM: In order to perform the microblading treatment in a safe manner, we kindly ask you to give sincere answers to the following questions regarding your medical health. Do you suffer from any of the following diseases or take any of the following medications? 1. Hemophilia YES NO 2. Diabetes mellitus YES NO 3. Hepatitis A, B, C, D, E, F YES NO 4. HIV + YES NO 5. Skin diseases YES NO 6. Eczema YES NO 7. Allergies YES NO 8. Autoimmune diseases YES NO 9. Are you prone to herpes? YES NO 10. Infectious diseases/high temperature YES NO 11. Epilepsy YES NO 12. Cardiovascular problems YES NO 13. Do you take blood thinners (anticoagulants)? YES NO 14. Are you pregnant? YES NO 15. Do you take any medications on daily basis? YES NO 16. Do you have a pacemaker fitted? YES NO 17. Do you have a problem with wound healing? YES NO 18. Have you consumed narcotics or alcohol in the past 24 hours? YES NO 19. Have you had a surgery, laser therapy or any other medical intervention in the past 14 days? YES NO If your response to any of the before mentioned questions was „Yes", please write down a detailed explanation. Before the explanation, be sure to indicate the question number to which it relates.