Patient Information

Patient Title *

First Name *

Last Name *

Email Address *

Telephone: *

DOB: *

Occupation: *

Do you smoke or vape nicotine? *

YesNo

How many a day?

Gender *

MaleFemale

Ethnic Origin: *

White CaucasianAfricanCaribbeanAsianIndian

If other:

Patient address: *

Street address *Street address line 2

City *

County

Postcode *

Country

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? *

YesNo

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? *

YesNo

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. *

YesNo

Will you be looking to finance your treatment? *

Do you believe this procedure will improve your health and well-being? *

YesNo

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? *

YesNo

Please provide details including dates.

Have you or a blood relative ever had a serious reaction to a local or general anaesthetic? *

YesNo

Comments

Did you have any serious postoperative complications? *

YesNo

Comments

Have you ever had a blood transfusion? *

YesNo

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? *

YesNo

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, TuberculosisAsthma (please specify if you had any hospital admissions with asthma in the last 6 months)BronchitisDiabetes: 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. HepatitisNone of the above

Comments:

Any Skin problems, including keloids or eczema? *

YesNo

Comments

Any Sight impairment/ Hearing impairment? *

YesNo

Comments

Do you drink alcohol? *

YesNo

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? *

YesNo

Comments:

Do you have any other illness or do you see your GP for any other problems? *

YesNo

Comments:

Do you have any psychological anxieties, worries or concerns? *

YesNo

Comments:

Do you suffer with depression? *

YesNo

Comments:

Have you or are you under the care of psychiatrist/psychologist or counsellor? Please specify below *

YesNo

Comments:

Have you recently experienced a major life event such as divorce bereavement or loss of income etc.? *

YesNo

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) *

YesNo

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? *

YesNo

Please specify and list the reaction

Further information: is there anything else we should know about your medical history? *

YesNo

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 signatureClear

Signature Date: *

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