Ala. Admin. Code r. 420-3-23-AE – Appendix E Medical History

Please Answer The Following Questions:
Do you presently have, or have you ever had:

1.	Hepatitis B?	Yes___ No___
2.	Hepatitis C?	Yes___ No___
3.	HIV/AIDS?	Yes___ No___
4.	Diabetes?	Yes___ No___
5.	History of Hemophilia or any other blood disorder/disease?	Yes___ No___
6.	Skin diseases or skin lesions?	Yes___ No___
7.	Sensitivities to soaps, disinfectants, etc.?	Yes___ No___
8.	History of allergies or adverse reactions to pigments, dyes, latex, etc.?	Yes___ No___
9.	Tuberculosis?	Yes___ No___
10.	Immune disorders?	Yes___ No___
11.	History of epilepsy, seizures, fainting or narcolepsy?	Yes___ No___
12.	Scarring (keloids)?	Yes___ No___
13.	History of heart murmer or any heart disease/condition?	Yes___ No___
14.	History of taking medicationssuch as anticoagulants that thin the blood and/or interfere with bloot clotting?	Yes___ No___
15.	Are you now under the influence of alcohol or drugs?	Yes___ No___
16.	Are there any other medical conditions which may affect your body art healing process?	Yes___ No___
17.	FEMALES: Are you pregnant or breast feeding/nursing?	Yes___ No___

IF YOU HAVE ANSWERED "YES" TO ANY OF THE ABOVE CONDITIONS, IT IS RECOMMENDED THAT YOU CONSULT WITH YOUR PERSONAL PHYSICIAN OR DENTIST BEFORE ANY PIERCING OR TATTOOING PROCEDURES ARE PERFORMED.
Signature:______________________________ Date:_________________
Print Name:___________________________ Date of birth:___________
Address:__________________________________________________________

City, State, & Zip:_______________________________________________
Phone Number: ( )-______________________________________________
Artist:___________________________________________________________
For Tattooing:
Design & Body Site(s):__________________________________________________________
__________________________________________________________________
For Piercing: Type Jewelry & Body Site(s):__________________________________________________________
For Branding: Design & Body Site(s):__________________________________________________________

Written aftercare instructions received? Yes___ No___

COMMENTS:

Author: Ronald Dawsey, Charlotte Denton

Statutory Authority: Code of Ala. 1975, §22-17A-7.

History: New Rule: Filed March 15, 2001; effective April 19, 2001; operative May 4, 2001. Repealed and New Rule: Filed December 20, 2006; effective January 24, 2007.