Patient Information
Patient Title
*
Mr
Dr
Other
First Name
*
Last Name
*
Email Address
*
Telephone:
*
DOB:
*
Occupation:
*
Do you smoke or vape nicotine?
*
Yes
No
How many a day?
Gender
*
Male
Female
Ethnic Origin:
*
White Caucasian
African
Caribbean
Asian
Indian
If other:
Patient address:
*
Street address
*
Street address line 2
City
*
County
Postcode
*
Country
Please select
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombi
Comoros
Congo (Brazzaville)
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Prior to your procedure taking place it is necessary to obtain an accurate and detailed medical history. Please complete the following document to the best of your knowledge providing as much detail as possible.
Please add these photos angles to the form for Dr Nurein to review before your free consultation.
Accepted formats include jpg, png and pdf.
Front View
*
Browse
Oblique View Left
*
Browse
Oblique View Right
*
Browse
Side View Left
*
Browse
Side View Right
*
Browse
Please answer all of the following questions
What is bothering you/concern and since when?
*
Is this condition affecting your Confidence/choice of clothing or causing psychological distress?
*
Yes
No
What is your goal/expectation in the treatment?
*
Have you seen a specialist or had any treatments before for this condition? If yes, please describe treatment and year
*
Have you tried any non-surgical method such as Exercise and Diet? Medication?
*
Do you train in the gym regularly/have a physical job/do contact sports?
*
Yes
No
Have you lost weight or suffered from obesity in the past? Please describe.
*
Is there any family history of difficulty or same area of concern? Please describe
*
Have you noticed any testicular lumps? Please see this site https://www.testicularcancerawarenessfoundation.org/self-exam
*
Yes
No
Have you noticed any of the following? Unexplained weight loss, persistent breast pain/discharge, family history of breast cancer, recent history (less than 2 years) of gynaecomastia.
*
Yes
No
Will you be looking to finance your treatment?
*
Do you believe this procedure will improve your health and well-being?
*
Yes
No
Next of Kin Details (we can contact)
Next of Kin name:
*
Next of Kin Tel (Mobile):
*
Patient Health Questionnaire
Please complete the following health questionnaire. Answer ALL questions
Do you have any of the following?
Have you ever had any other operations?
*
Yes
No
Please provide details including dates.
Have you or a blood relative ever had a serious reaction to a local or general anaesthetic?
*
Yes
No
Comments
Did you have any serious postoperative complications?
*
Yes
No
Comments
Have you ever had a blood transfusion?
*
Yes
No
Comments:
What is your most recent blood pressure if known? (Parameters: High blood pressure is over 140/90)
*
I don't know
I know
Comments:
Do you have any difficulty with pain threshold with local anaesthesia before?
*
Yes
No
Comments:
Have you suffered from any of the following?
*
Palpitations or heart murmur?
Heart attack, chest pain or angina?
Blackouts or faints?
Stroke or mini stroke?
Epilepsy or fits? Please date your last fit below.
Clotting problem , thrombosis (DVT, PE, Blood clot), Factor V Laden?
Anaemia, excessive bleeding or bruising?
Any infective/blood disorders? e.g. Hepatitis C, HIV, Tuberculosis
Asthma (please specify if you had any hospital admissions with asthma in the last 6 months)
Bronchitis
Diabetes: Insulin dependent / Tablet controlled?
Arthritis including joint and neck complaints?
Thyroid problems?
Multiple sclerosis?
Indigestion heart burn or bowel problems?
Kidney problems?
Jaundice or liver disease? e.g. Hepatitis
None of the above
Comments:
Any Skin problems, including keloids or eczema?
*
Yes
No
Comments
Any Sight impairment/ Hearing impairment?
*
Yes
No
Comments
Do you drink alcohol?
*
Yes
No
How many units per week?
Do you use recreational drugs? Cannabis / Heroin / Cocaine Ecstasy etc. Any history of anabolic use? How often used, if yes please specify below?
*
Yes
No
Comments:
Do you have any other illness or do you see your GP for any other problems?
*
Yes
No
Comments:
Do you have any psychological anxieties, worries or concerns?
*
Yes
No
Comments:
Do you suffer with depression?
*
Yes
No
Comments:
Have you or are you under the care of psychiatrist/psychologist or counsellor? Please specify below
*
Yes
No
Comments:
Have you recently experienced a major life event such as divorce bereavement or loss of income etc.?
*
Yes
No
Comments:
Medication
Are you currently taking any medication? If Yes - List current medication below (including tablets, patches, injections, inhalers, over the counter supplements, herbal or recreational medicines)
*
Yes
No
Please list below
Please note, patients on beta blockers may be asked to stop them 1-2 weeks pre-op
Allergies and Sensitivities
Do you have any allergies or sensitivities?
*
Yes
No
Please specify and list the reaction
Further information: is there anything else we should know about your medical history?
*
Yes
No
If yes please provide more details below:
How did you hear about us?
*
Have you seen our YouTube videos especially the Q&A series or other websites?
*
Yes
No
Please tick each statement to confirm that you have understood it.
I confirm that the medical history contained in this document is accurate and complete to the best of my knowledge.
*
I understand that withholding any medical information will be detrimental to my health and safety during any procedure that Dr Nurein agrees to undertake
*
I understand that photographs will be taken at the consultation to be kept on my file for reference if treatment goes ahead. These are confidential and will not be used if revealing my identity.
*
I acknowledge that my procedure is subject to Dr. Nurein’s consultation and medical clearance.
*
GDPR Consent
I consent to be contacted by Be Cosmetic Clinics or Dr Nurein's Team.
*
I consent
As per the latest GDPR regulations, we are obligated to obtain your explicit written consent to be able to contact you and share your personal details with the clinic or hospital where we are consulting and performing your procedure (we will use only the above given details to contact you unless stated otherwise).
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
*
Yes
No
Current Health Practitioner Details
GP Surgery Name:
*
GP Surgery Email:
*
Proving an email / this field is mandatory
GP Surgery Phone:
*
GP Surgery Address:
*
Patient Signature:
*
Draw signature
|
Type signature
Clear
Signature Date:
*
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