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SECRET SIDEWALK TATTOOS <br /> MEDICAL HISTORY <br /> Name: Date:_/� <br /> Date of Birth: Female Male Other <br /> Emergency Contact- Name: Phone Number: <br /> PLEASE INDICATE `YES' OR `NO' FOR EACH APPLICABLE CONDITION <br /> Yes No Yes No <br /> HEPATITIS HERPES <br /> HIV/AIDS EPILEPSY/SEIZURE DISORDER <br /> DIABETES SCARRING/KELOIDING <br /> BLOOD THINNERS PREGNANCY/NURSING <br /> FAINTING OR DIZZINESS DO YOU REQUIRE ANTIBIOTICS PRIOR TO <br /> SURGERY OR DENTAL PROCEDURE? <br /> T.B HISTORY OF HERPES INFECTION <br /> AT THE PROCEDURE SITE? <br /> ASTHMA HISTORY OF HEMOPHILIA OR <br /> OTHER BLEEDING DISORDERS? <br /> ALLERGIC REACTION TO LATEX OTHER: <br /> ALLERGIC REACTION TO <br /> ANTIBIOTICS <br /> ECZEMA/PSORIASIS <br /> SKIN CONDITION <br /> HISTORY OF CARDIAC VALVE DISEAS <br /> HEART CONDITION <br /> HEMOPHILIA <br />