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<br /> SECRET SIDEWALK TAT TO OS <br /> MEDICAL HISTORY <br /> <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 /> <br />T.B HISTORY OF HERPES INFECTION <br />AT THE PROCEDURE SITE? <br /> <br />ASTHMA HISTORY OF HEMOPHILIA OR <br />OTHER BLEEDING DISORDERS? <br /> <br />ALLERGIC REACTION TO LATEX OTHER:____________________________________ <br />____________________________________________ <br /> <br />ALLERGIC REACTION TO <br />ANTIBIOTICS <br /> <br />ECZEMA/PSORIASIS <br />SKIN CONDITION <br />HISTORY OF CARDIAC VALVE DISEAS <br />HEART CONDITION <br />HEMOPHILIA <br /> <br /> <br />