HEALTH QUESTIONNAIRE. You warrant, declare and acknowledge that:
HEALTH QUESTIONNAIRE. All questions must be answered completely for each person applying for coverage on this application or the application will be returned. Any knowing misrepresentation as to the presence or severity of any health condition, impairment, or disease could result in retroactive termination of coverage. Any failure to notify RMHP of any medical condition, impairment, disease, or change in any applicant’s health status that occurs or is diagnosed between the date of application and the later of the effective date of coverage or the date coverage is approved could also result in retroactive termination of coverage. RMHP shall have the right to request and review additional information regarding health history and any change in health status that occurs between the date of application and the effective date of coverage. This additional information may be used to determine if RMHP will accept or decline your application prior to the effective date of coverage. No notice of acceptance related to your application can bind RMHP to coverage until the effective date of coverage, and failure to provide additional requested information could result in your application not being accepted.
HEALTH QUESTIONNAIRE. These questions are to screen for people who could transmit the virus causing COVID-19. The information will remain confidential and reviewed only by local clergy, the District Superintendent, the Xxxxxx, the Chancellor or the Department of Health for possible contact tracing. Please return completed form by email to your group event leader at least 24 hours before you plan to attend your scheduled event. If you do not have email, call your leader and provide the information below on the telephone. Persons who have 2 or more of the listed symptoms or who have been in contact with anyone experiencing symptoms of COVID-19 in the past 14 days cannot attend at this time.
HEALTH QUESTIONNAIRE. To perform the Permanent Makeup service in a safe manner, please answer the following health questions truthfully. {insert your name} and the Company will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether I can receive the service. Do you suffer from the following diseases or are you taking any of these medications? Hemophilia? Diabetes mellitus (diabetes)? YES YES NO NO Xxxxxxxxx A, B, C, D, E, F? YES NO HIV+? YES NO Skin diseases? YES NO Eczema? YES NO Allergies? If so, what kind? YES NO Autoimmune diseases? YES NO Are you prone to cold cores/herpes simplex virus? Infectious diseases / high fever? YES YES NO NO Epilepsy? YES NO Cardiovascular problems? YES NO Are you taking medication for blood thinning (anticoagulants)? YES NO Are you pregnant or breastfeeding? YES NO Are you taking any medications on daily basis? YES NO If so, list what they are for Do you have a pacemaker? YES NO Do you have problems with healing of wounds? YES NO Do you or have you ever had trouble being numbed in a medical setting? YES NO Have you consumed drugs or alcohol in the last 24 hours? YES NO Did you in the last 14 days undergo surgery, were you exposed to radiation or had any other medical interventions? YES NO What is your skin type? Circle one. NORMAL/DRY OILY COMBINATION SENSITIVE Were you able to follow pre-care instructions to properly prepare for this procedure? YES NO This information is confidential and it shall also be handled in that way. The Company assumes no liability in case of giving false information.
HEALTH QUESTIONNAIRE. To perform the Brow Lamination procedure in a safe manner, please answer the following health questions truthfully. We will keep all information disclosed in a confidential manner and will use it only for purposes of determining whether you are an ideal candidate for this procedure. Yes No Hemophilia Yes No Diabetes Yes No Hepatitis (A,B,C,D) Yes No HIV Yes No Skin Diseases Yes No Eczema Yes No Allergies Yes No Cardiovascular problems Yes No Are you taking medication for blood thinning (anticoagulants)? Yes No Are you pregnant? Yes No Do you have a pacemaker? Yes No Have you tinted your eyebrows in the last 6 months using henna or tint/dye? Yes No Have you ever been allergic to, or have had an allergic reaction to perm solution? Yes No Have you ever been allergic to, or have had an allergic reaction to Hair Dye? If you answered yes to any of the above statements please state what they may be and how severe it is presently. Photography Release Consent We would like your permission to use these photos for advertising. For example, in portfolios, online, and in print ads, etc. Your consent is necessary regarding this. Please circle and indicate with your signature if you would like your photos used or not used in advertising. YES, feel free to use them NO please do not use them Signature:
HEALTH QUESTIONNAIRE. This will include screening questions for active TB, details of previous immune status investigations and BCG status: Have you coughed up blood in the last year? Yes/No Have you had any recent unexplained weight loss? Yes/No Do you currently have any of the following symptoms for longer than three weeks: Cough Yes/No Sputum/spit Yes/No Shortness of breath Yes/No Significant fatigue Yes/No Night sweats or fever Yes/No Chest pain Yes/No Have you had a previous BCG vaccination? Yes/No If yes, approximate date: Have you ever had a Mantoux test? If yes, approximate date: Have you had previous contact with a known case of TB? Yes/No If yes, approximate date: Have you had TB in the past? Yes/No If yes, approximate date: For how long was treatment taken? Type of treatment: Name of doctor attended for this: At first attendance, the presence or absence of a BCG scar will be documented.
