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Health Questionnaire
Client: [Client Name]
DOB: [Client Dob]
Please answer each question truthfully:
•Pregnant or breastfeeding?
Yes
No
Allergies (if any)::
Current medications (if any)::
•Bleeding disorder?
Yes
No
•Diabetes?
Yes
No
•Heart condition?
Yes
No
•Skin conditions?
Yes
No
If yes, describe::
•Immune system issues?
Yes
No
•Recent surgery?
Yes
No
If yes, provide details::
Other notes::
I certify that I have answered the above questions truthfully and to the best of my knowledge.
Client Signature: ______ Date: ______
Artist/Staff Signature: ______ Date: ______