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MEDICAL QUESTIONIRE WORK ETHIC TATTOO STUDIO LLC (Y / N) Allergic reaction to latex (Y / N) Allergic reaction to antibiotics (Y / N) History of hemophilia or other bleeding disease (Y / N) History of cardiac valve disease (Y / N) Requirements for antibiotics prior to dental or surgery procedures (Y / N) Other risk factors for blood borne pathogen (Y / N) pregnant (Y / N) HIV/ Other (Y / N) History of herpes infection at the procedure site (Y / N) History of diabetes (Y / N) current medications AFTERCARE INSTRUCTIONS CLIENT NAME: The following verbal and/or written instructions were communicated to the client: 1.Information on the care of the procedure site. 2.Restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with animals, and the duration of the restrictions. 3.Signs and symptoms of infection including but not limited to redness, swelling, tenderness of the procedure site, red streaks going from the procedure site towards the heart, elevated body temperature, or purlent drainage from the procedure site. 4.Instructions to call a physician if any of the addressed signs and symptoms appear or for any other reason related to the Body Art procedure(s). 5.If physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body Art facility and practitioner of the problem and the resolution by a physician or clinic. This information shall be placed in the client's file. 6.Clean area serval times a day, wash hands before applying ointment A&D or Aquaphor. To the best of my knowledge g this mformataon is correct. Practitioner Signature: 1 have received aftercare instructions: Practitioner Signature: _ Date Client Signature:_ Date: ____ ARTIST ONLY LOT- LOT- LOT- LOT.