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Please fill out the following table with a c tveck to indicate if any of the following <br />relate to yourself. <br />Mitral Valve Prolapsed Heart Murmur <br />Rheumatic Fever Pacemaker <br />Artificial Heart Valves Anaemia <br />Haemophilia 0.„1,...,...a o _ ,, <br />Blood <br />VIU uswrvances <br />Liver Disease <br />Kidne Disease <br />Glaucoma <br />Stomach Ulcers <br />Tumours Growths or Cy2ts <br />Cancer <br />Tuberculosis <br />Stroke <br />HIV <br />Prosthetic Hi or JointI <br />Svstemic Lupus Erythematosus <br />Hepatitis <br />Shingles <br />Seizures <br />Impetigo <br />Cataracts <br />31urred Vision <br />Dry Eyes <br />Do you suffer from eye Infections <br />Alopecia <br />Dccular Herpes <br />Watery Eyes <br />Zontact Lenses <br />Eyelid Surgery <br />Chapped Lips <br />Trichollomania <br />Recent Hair Loss <br />Cold Sores (herpes simplex) <br />Auto immune conditions <br />Gore-Tex Im (ants/Silicone injections <br />ether Tattoos <br />Fat Injections <br />3ruise or Bleed Easily <br />Botox Enhancement <br />Jse of Sun bed <br />Dermal Fillers Le res [ane <br />)ate of last eyelash/ eyebrow tint <br />Do you have HeahnR Problems <br />Chemical or laser peel within 6 months <br />Do you scar in a raised manner? <br />Retin A within 6 months <br />Do your scars heal a darker color <br />AHA preparations within last 2 weeks <br />Keloid Scars <br />Sensitivity to Cosmetics <br />l� <br />Acutance within 6 months Do you tan !hula,r . <br />Steroids within 6 months .Asthma <br />-- Other risk factors for blood borne pathogens <br />` lS$It3'a 4,CIIL yA4� lS fst <br />others conditions <br />Client Name Sicnature nate <br />