Please answer the following questions to the best of your ability. This information is confidential and will only be used to ensure your safety during the tattoo procedure.
1. Are you currently taking any medications? ☐ Yes ☐ No
If yes, please list: ________________________________________
2. Do you have any allergies? ☐ Yes ☐ NoIf yes, please specify (e.g., latex, inks, medications): ___________________________________________________
3. Have you ever experienced any of the following? (Check all that apply)
☐ Skin disorders (eczema, psoriasis, etc.) ☐ Heart conditions
☐ Diabetes ☐ Hepatitis or other liver conditions ☐ HIV/AIDS
☐ Blood disorders (e.g., hemophilia) ☐ Autoimmune disorders
☐ Keloid scarring ☐ Other (please specify): ___________________________________________________
4. Have you had any surgeries in the past year? ☐ Yes ☐ No
If yes, please specify: ________________________________________
5. Are you pregnant or nursing? ☐ Yes ☐ No
6. Have you consumed alcohol or recreational drugs in the past 24 hours?☐ Yes ☐ No
7. Do you have any other medical conditions that may affect the healing of a tattoo? ☐ Yes ☐ No
If yes, please specify: ___________________________________________________
8. Have you ever had a negative reaction to a tattoo or body art procedure? ☐ Yes ☐ No
If yes, please explain: ___________________________________________________
9. Do you have any other concerns or questions regarding the tattoo procedure? ☐ Yes ☐ No
I acknowledge that the above information is accurate to the best of my knowledge. I understand that failure to disclose any relevant medical information may affect the safety and outcome of the tattoo procedure.
