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Answer Yes or No: <br /> Allergies: Diseases Health <br /> Antibiotics: Hepatitis: Heart Disease: <br /> Metals: Tuberculosis: High Blood Pressure: <br /> Soaps: Gonorrhea: Diabetes: <br /> Latex: Syphilis: Pregnant: <br /> Alcohol: HIV/AIDS: Prone to Faintness: <br /> Cosmetics: Herpes: Skin Disease/Rash: <br /> Adhesives: Staph: Epilepsy: <br /> Petroleum: Auto-Immunity: Hemophilia: <br /> Lanolin Oil: Asthma: Proneto Scaring/Keloiding: <br /> Lidocaine: Infections: Psoriasis: <br /> Shellfish: Cardiac Valve Disease: Blood Thiners: <br /> Herpes at procedure site: Eczema: <br /> Medications: <br /> Requirements for <br /> antibiotics prior to surgery <br /> or dental procedures: <br /> Bleeding disorders: <br /> Other Risks for blood <br /> borne pathogens: <br /> Other(specify): <br /> Client Full Name: _ Artist Full Name: <br /> Client Signature: Artist Signature: <br /> Date: Date: <br /> Government-Issued ID Type: <br /> Date of Birth: <br /> How long since you last ate: <br /> Tattoo Description: <br /> Down 2 Earth Tattoo,150 N Main Street Manteca,CA 95336 <br />