MEDICAL HISTORY

Patient's First Name *

Patient's Last Name *

Email Address *

Phone Number: *

DOB: *

Occupation: *

Gender: *

Ethnic Origin: *

Patient’s Address: *

Street address *Street address line 2

City *

State

Postcode *

Country

What treatment are you enquiring about? *

What is bothering you/concern and since when? *

Please include photos for Dr Braham to review, include as many angles as possible. *

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Do you smoke or vape nicotine? *

Yes No

How many a day? *

Do you drink alcohol? *

Yes No

How many units per week? *

Are you pregnant or breastfeeding? *

YesNo

Do you have any Allergies (Latex, LA, Medications, Others…) ? *

YesNo

Please specify below: *

Are you on any Medication (Pills, Anti-depressants, Blood Thinners, Others..) ? *

YesNo

Please specify below: *

Do you suffer from Needle Phobia, Anxiety or Mental Health Condition? *

YesNo

Please specify below: *

Do you suffer from epilepsy or any neurological condition? *

YesNo

Please specify below: *

Do you suffer from any Medical Condition (Diabetes, Hypertension, Asthma….) ? *

YesNo

Please specify below: *

Have you had any surgery in the past? *

YesNo

Please specify below: *

Are you awaiting the results of any investigations? *

YesNo

Please specify below: *

Is the problem you are enquiring about new or old? *

NewOld

Please specify below: *

Height: *

Weight: *

BMI:

I consent to be contacted by Be Cosmetic Clinics or Dr Braham’s Team. *

It is good practice that we inform your GP but if you cannot provide their details we will provide you with a letter to give to your GP. If you are under the care of any other health care professional please provide full details below.

I consent for Be Cosmetic to contact my GP for my medical history. *

YesNo

Current Health Practitioner Details

GP Surgery Name: *

GP Surgery Email: *

GP Surgery Phone Number: *

GP Surgery Address: *

Patient’s Signature: *

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Patient’s Signature Date: *

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