Initial Intake Form

    Please enter the following information as accurately as possible.

    Today's Date *

    Name *

    Phone *

    Email *

    How would you like us to contact you? *

    Age *

    Gender *

    Ethnicity *

    Height *

    Weight *

    Occupation *

    City & State *

    What do you hope to get out of your appointment with us? *

    At what age did you first notice signs of Breast Enlargement or Gynecomastia and do you remember what triggered it?

    Has your condition gotten better or worse at any point? Do you remember what may have triggered the change?

    Do any men in your family have Breast Enlargement or Gynecomastia? *


    Do you have any blood relatives you have been diagnosed with breast cancer? *


    Do you have breast enlargement on only one side or both? *

    One sideBoth sides

    Please upload a photo of your chest. (2MB maximum size)

    Have you at any time experienced breast pain or tenderness? *


    Have you at any time experienced nipple discharge? *


    Have you been seen by a physician for Breast Enlargement or Gynecomastia? *


    Please indicate any treatments you have had for this condition in the past, the date of treatment, and any results you may have noticed.

    Please list all medical conditions for which you have been treated.

    Please list any medications you are CURRENTLY taking.

    Please list all non-prescribed drugs or medications you Currently take or taken in the past.

    Have you ever used anabolic steroids or hormonal substances? *


    Have you had cosmetic surgery before? *


    If yes, please indicate the cosmetic procedures

    Have you ever had an allergic reaction? If so, please indicate what was the cause, when and describe the reaction.

    Do you smoke? *


    Do you drink alcohol? *


    If yes, how often and how much do you drink?

    Does your skin tend to scar easily? *


    Do you exercise often? *


    How did you hear about us?

    What are your hobbies/passions?

    When are you hoping to have treatment for your Male Breast Enlargement or Gynecomastia? *

    What is motivating you to have treatment for Gynecomastia?

    Is there anything else you would like us to know?

    I understand that the surgical treatment I'm seeking is not a substitute for more comprehensive medical diagnosis or treatment of more serious or systemic conditions for which I should see my physician or other qualified medical specialist. I also understand that I am responsible for seeking diagnosis and treatment for any mental or other physical ailment that I am aware of from my physician or other qualified providers. Because male breast reduction procedures may not be advisable to be performed under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly and understand that no treatment is guaranteed to produce a specific result. I agree to keep Dr. Edwin Ishoo and Boston Cosmetic Specialists updated in writing as to any changes in my medical profile and understand that there shall be no liability on Dr Edwin Ishoo or Boston Cosmetic Specialists and should I fail to do so. I also understand and confirm that submission of this form does not constitute nor establishes a doctor-patient relationship with Dr. Edwin Ishoo.