Laserfiche WebLink
CLIENT'S MEDICAL QUESTIONNAIRE <br /> PlFase be as accurate as possible when filling in the following information <br /> Yes No <br /> ❑ ❑ Are you currently pregnant or breastfeeding? <br /> ❑ ❑ Have you ever had a herpes infection at the eyebrows? <br /> ❑ ❑ Are you diabetic or have had diabetes in the past? <br /> ❑ ❑ Do you have allergic reactions to latex? <br /> ❑ ❑ Do you have allergic reactions to antibiotics? <br /> ❑ ❑ Have you ever had hemophilia or other bleeding disorders? <br /> ❑ ❑ Have you ever had cardiac valve disease? <br /> ❑ ❑ <br /> Are you taking any medication currently? <br /> If yes, please explain: <br /> ❑I Do you have a requirement for antibiotics prior to surgery or dental <br /> procedures? <br /> ❑ ❑ Do you have any other risk factors for blood borne pathogens? If yes, <br /> please explain: <br />