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