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PMU Medical Intake & Health Questionnaire
Client: [Client Name]
DOB: [Client Dob]
Date: [Form Date]
Please answer all questions honestly. This information is used only to determine whether this procedure is safe for you. It is not shared with third parties.
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Current Medications
List all current medications, supplements, and vitamins (include dosage if known)::
•Are you taking any of the following?
Blood thinners (aspirin, warfarin, clopidogrel, heparin, etc.)
Retinoids / Vitamin A derivatives (Accutane, Retin-A, tretinoin)
Oral corticosteroids
Immunosuppressants (methotrexate, cyclosporine, etc.)
Antibiotics (currently taking)
Other prescription medications: [Other Rx Details]
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Medical Conditions
Check all that apply:
Diabetes (Type 1 or Type 2)
Heart condition or pacemaker
Autoimmune condition (lupus, rheumatoid arthritis, MS, etc.)
Thyroid disorder
Hemophilia or other bleeding/clotting disorder
Hepatitis B or C
HIV / AIDS
Epilepsy or seizure disorder
Chronic skin conditions (eczema, psoriasis, rosacea, vitiligo)
History of keloid or hypertrophic scarring
Active cancer treatment (chemotherapy or radiation)
Cancer treatment completed within the last 12 months
None of the above
Additional details about any checked conditions::
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Pregnancy and Nursing
•Are you currently pregnant?
Yes
No
Unsure
•Are you currently nursing/breastfeeding?
Yes
No
PMU procedures are generally not recommended during pregnancy or while nursing. If you checked Yes or Unsure, please consult your healthcare provider before proceeding.
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Allergies
•Do you have known allergies to any of the following?
Latex
Nickel or other metals
Tattoo or cosmetic pigments
Topical anesthetics (lidocaine, benzocaine, tetracaine)
No known allergies
Other: [Allergy Other Details]
Describe any past allergic reactions (what caused it, what happened)::
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Skin and Prior Cosmetic Work
•Do you have any of the following in or near the treatment area?
Previous permanent makeup or microblading
Decorative tattoo
Scar tissue
Active breakout, cold sore, or wound
None of the above
•Recent cosmetic procedures in the treatment area (past 4 weeks)?
Botox or neuromodulator injection
Dermal filler
Laser treatment or chemical peel
None
•Date of most recent procedure (if any): [Recent Procedure Date]
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Sun Exposure and Skincare
Describe your typical sun exposure and tanning habits (relevant to fading)::
•Do you use any of the following on the treatment area?
Topical retinol or vitamin A products
AHA / BHA / glycolic acid products
None of the above
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Consent to Proceed
I certify that I have answered all questions truthfully and to the best of my knowledge.
I understand that withholding relevant health information may affect the safety of this procedure and that the artist/studio is not liable for complications arising from undisclosed conditions.
I understand that if any of my answers indicate a potential contraindication, I may be asked to obtain medical clearance from my healthcare provider before proceeding.
I understand that this questionnaire is a screening tool only and does not constitute medical advice or diagnosis.
Client Signature: ______ Date: ______
Artist/Staff Signature: ______ Date: ______