Health History

1

Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

4

To avoid unforeseen complications, please answer the following questions. Answering “yes” to any of these questions does not necessarily preclude you from receiving permanent make-up. We will keep this information in your file for 1 year. Please notify your technician if there are any changes to your medical profile in the future.

Please write “YES” or “NO” to all questions or circle the appropriate answer. Thank you!

5

Are you pregnant or nursing* This field is required.

YESNO

6

Do you have any allergies to food, medication, anesthetics, or other substances?* This field is required.

YESNO

7

Please List Allergies Below

8

Do you have problems getting numb at the dentist?* This field is required.

Getting Numb

Staying Numb

Both

I don't have any problems with numbing!

10

Have you had previous permanent makeup ?* This field is required.

YESNO

11

Which Areas and When?

12

Do you have any Communicable diseases your technician should be aware of, Including: HIV/AIDS, Hepatitis A, B, or C, or Tuberculosis* This field is required.

YESNO

13

Please Indicate which?

14

Do you have any diagnose medical conditions? * This field is required.

YESNO

16

Please list any other medical conditions you may have or explain any pertinent details regarding your condition.

17

Do you take any immunosuppressive, anti-inflammatory, or steroid medications?* This field is required.

YESNO

18

Do you have any conditions or take any medications that can cause thin blood or excessive bleeding?* This field is required.

YESNO

19

Please list any prescribed medications and which condition they apply to.* This field is required.

20

Which over the counter medications, vitamins, or supplements do you take daily?* This field is required.

21

Have you ever had problems previously with tattoos healing or fading prematurely?* This field is required.

YESNO

22

Please explain.

23

Are you currently undergoing radiation therapy, or have you completed treatment within the last year? * This field is required.If so a Physician must provide written consent.

YESNO

24

Do you have Keloid scarring?* This field is required.

YESNO

25

Where is it located? * This field is required.

26

Are you currently using Alpha Hydroxy, Retin-a or Glycolic Skin care products* This field is required.

YESNO

27

How frequently, When was the last use?* This field is required.

28

Which Skin care products do you use to wash, remove makeup, and moisturize your skin?* This field is required.

29

Have you used eyelash serum in the last 6 months? * This field is required.

YESNO

30

When was the last use? * This field is required.

31

Do you wear contact lenses? * This field is required.Prescribed or Cosmetic.

YESNO

32

Have you had any Alcohol, Aspirin, or Blood thinning products within the last 72 hours? * This field is required.

YESNO

33

Which Products and When?* This field is required.

34

Have you had any Mood-altering medication in the last 24 hours?* This field is required.

YESNO

35

Please list. * This field is required.

36

Have you consumed any anticoagulant pain relievers in the last 48 hours? * This field is required.Aspirin, Excedrin, Ibuprofen, Aleve, Advil, Naproxen.

YESNO

37

Do you take antibiotics prior to a dental appointment?* This field is required.

YESNO

38

Do you have any medical conditions that would require a physician's consent to be tattooed? * This field is required.

YESNO

39

Have you had botox or facial fillers in the past 3 months?* This field is required.

YESNO

40

When? * This field is required.

41

Have you had any surgeries in the last 30 days or do you plan to have a surgery in the next 30 days? * This field is required.Any surgery minor or major

YESNO

42

Please explain. * This field is required.

43

Client Signature* This field is required.

44

Date* This field is required.

Date

45

Who is your Technician? * This field is required.