1. Ord/swim pool, body art - Laserfiche WebLink

PERSONAL HISTORY Please answer the following questions to the best of your ability. I *Have you ever had hepatitis? I *Have you ever tested HIV positive? *Do you have any allergies? Yes - No - Yes No - Yes No Yes - No- *Are you a diabetic? *Do you have high blood pressure/heart disease? Yes- No- *Do you have epilepsy, seizures, fainting, or dizziness? Yes- No- * Are you a hemophiliac, have a bleeding disorder, or family history of bleeding? Yes- No- *Do you have a history of skin diseases, easy scaring, easy bruising, open sores, skin sensitivities? Yes- No- * Are you taking any prescription medication other than routine antibiotics, allergy medication, or birth control pills Yes- No- *FEMALES: Are you pregnant? Yes- No *Do you currently have a contagious disease i.e., Tuberculosis, Mononucleosis, Pneumonia, or Sexually Transmitted Diseases? Yes- No- I *Do you now have, or have you ever had problems with your immune system? Yes- No- *Do you have any serious physical or mental health problems? Yes- No- Have you been hospitalized in the past 12 months? Explain: Are you under the influence of drugs or alcohol? Yes- No Yes- No- I By my signature below, I certify that I understand and have answered the above questions truthfully and to the best of my knowledge. I . Signature Date Print name Date of birth Address Phone no.