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MEDICAL QUESTIONIRE <br />Allergic reaction to latex <br />(Y/ N) Allergic reaction to antibiotics <br />(Y/ N) History of hemophilia or other bleeding disease <br />(Y/ N) History of cardiac valve disease <br />(Y/ N)Requirements for antibiotics prior to dental or surgery procedures <br />(YI N)Other risk factors for blood borne pathogen <br />(Y/ N) Are you pregnant? <br />(Y/ N)Are you taking any medication? <br />(Y/ N) History of diabetes? <br />(Y/ N)History of herpes infection at the procedure site <br />AFTERCARE INSTRUCTIONS <br />CLIENT NAME: <br />The following verbal and/or written instructions were communicated to the client: <br />1. Information on the care of the procedure site. <br />2. Restrictions on physical activities such as bathing, recreational water activities, gardening, or contact with <br />animals, and the duration of the restrictions. <br />3. Signs and symptoms of infection including but not limited to redness, swelling, tenderness of the procedure <br />site, red streaks going from the procedure site towards the heart, elevated body temperature, or purulent <br />drainage from the procedure site. <br />4. Instructions to call a physician if any of the addressed signs and symptoms appear or for any other reason <br />related to the Body Art procedure(s). <br />5. If physician care is required by the client related to the Body Art procedure(s), the client is to notify the Body <br />Art facility and practitioner of the problem and the resolution by a physician or clinic. This information shall be <br />placed in the client's file. <br />6. Clean tatt <br />oo with antibacterial soap and water. Pat down tattoo with a clean <br />paper towel <br />and <br />Apply a <br />light amount of Aquaphor or A&D ointment on tattoo. Repeat this Process 2 <br />or 3 times a <br />day. <br />To the best of my knowledge this information is correct: <br />Practitioner Signature: <br />I have received aftercare instructions: <br />Date: <br />Client Signature: Date: <br />