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TATTOO <br />MEDICAL <br />QUESTIONAIRE <br />CLIENT INFORMATION FORM <br />APPOINTMENT DATE: APPOINTMENT TIME: <br />FULL NAME DATE OF BIRTH: <br />ADDRESS: <br />CITY : STATE: <br />ZIP/POSTAL CODE: PHONE NUMBER: <br />EMAIL ADDRESS: <br />TO AVOID UNFORSEEN COMPLICATIONS, PLEASE <br />ANSWER THE FOLLOWING QUESTIONS: <br />Y N ARE YOU OVER THE AGE OF 18? <br />Y N TAKE FISH OIL: DATE LAST TAKEN: <br />Y N ANY MOOD -ALTERING DRUGS WITHIN THE LAST 12 HOURS? (I.E. WELLBUTRIN, XANAX, PROZAC) <br />Y N DO YOU HAVE ANY HISTORY OF COLD SORES, HERPES, OR FEVER BLISTERS? <br />Y N ARE YOU SENSITIVE/ALLERGIC TO LATEX/LIDOCAINE/EPINEPHRINE/ANTIBIOTICS? <br />Y N CHEMICAL OR LASER PEEL? DATE: <br />Y N DO YOU HAVE PROBLEMS WITH HEALING? <br />Y N PREVIOUS PROBLEMS WITH TATTOOS? <br />Y N ARE YOU CURRENTLY UNDERGOING RADIATION OR CHEMOTHERAPY? <br />Y N ARE YOU CURRENTLY TAKING ANY CHEMOTHERAPY MEDICATIONS? <br />Y N ARE YOU CURRENTLY USING RETIN-A OR THE LIKE? DATE OF LAST USE: <br />Y N DO YOU WEAR CONTACT LENSES? <br />Y N ARE YOU ALLERGIC TO ANY METAL? <br />Y N PREVIOUS PERMANENT MAKEUP/MICROBLADING? <br />Y N HAVE YOU HAD TATTOOS BEFORE? <br />Y N MEDICATION, INCLUDING IMMUNOSUPPRESSIVE, SUCH AS ANTI-INFLAMMATORY OR STEROIDS? <br />Y N ARE YOU ALLERGIC TO TOPICAL ANESTHETICS? <br />Y N IS THERE ANY HISTORY OF SKIN DISEASES OR REMARKABLE SKIN SENSITIVITIES? <br />Y N ARE YOU PREGNANT/NURSING? <br />Y N ARE YOU REQUIRED TO TAKE ANTIBIOTICS DURING DENTAL OR INVASIVE MEDICAL PROCEDURES? <br />Y N DO YOU HAVE ANY DRUG ALLERGIES? IF YES, LIST IN SPACE PROVIDED AT THE END OF FORM. <br />Y N ARE YOU CURRENTLY TAKING MEDICATION FOR HIGH OR LOW BLOOD PRESSURE? <br />Y N FREQUENT SUN EXPOSURE/TANNING BEDS <br />Y N HAVE YOU CONSUMED ALCOHOL TODAY? <br />Y N DID YOU WORK OUT TODAY? <br />Y N ARE YOU PLANNING ON ANY FACIAL SURGERY IN THE NEAR FUTURE? (FACE LIFT, EYELIDS, OR <br />BROW LIFT) <br />ADORN BEAUTY INK <br />