Demographic Details:
Dr. Afzal Hussain
Woodbank surgery
2-Hunstanton Drive
Brandlesholme,
Bury: BL8 1EG
CIRCUMCISION SERVICE
HEALTH ASSESSMENT / PROCEDURE RECORDS
PARENTS NAMES
Father (please print) ……………………………………………………………………………………
Mother (please print) ……………………………………………………………………………………
Main language ………………………………………………………………………………………….
Address…………………………………………………………………………………………………..
…………………………………………………………………………………………………………….
Telephone Number ………………………………………….
Ethnicity …………………………………….. Religion …………………………………………
BABY’S DELIVERY DETAILS
Baby’s Date of Birth ………………………………. Age …………………………………...
Gestation: ………………………………….. Birth Weight ………………………..................
Type of Delivery …………………………………………………………………………………………
PROBLEMS AFTER BIRTH: …………………………………………………………………………
CURRENT HEALTH STATUS
Feeding: Breast: Yes / No Bottle: Yes / No Both: Yes
Current Weight ……………………………..
Jaundice: Yes / No Vomiting: Yes / No Resp problems: Yes / No Rashes: Yes / No
Comments:
…………………………………………………………………………………………………………….
…………………………………………………………………………………………..........................
OBSERVATIONS if needed:
Temperature ……………… Pulse ………………Respiratory ……………… O2 sats:…………………
Dr. Afzal Hussain
FAMILY MEDICAL HISTORY
Mum’s ………………………………………………………………………………………………………
Dad’s ……………………………………………………………………………………………………….
Siblings …………………………………………………………………………………………………..
SPECIFIC
Bleeding Disorders: …………………………………………………………………………………….
Allergies ………………………………………………………………………………………………….
PRE-PROCEDURE
Pre.Op Paracetamol given: Yes / No
Written information given: Yes / No
PROCEDURE
Date: ……………………………………………..
Local Anaesthetics: Type: …………………………………………………………….
Dosage: ……………………………………………………………
Time Given: ……………………………………………………….
Time procedure commenced: …………………………………………………………………………
Time procedure finished: ………………………………………………………………………………
Plastibell size: ………………………………………………. Batch No: …………………………….
NAME AND SIGNATURE OF PERSON UNDERTAKING CIRCUMCISION
Name: ……………………………………………………… Designation: ……………………………
Signature: ……………………………………………………………………………………………….
PROCEDURAL NOTES / OBSERVATIONS
Time: …………………………. ………….. Pain score (1-5): ……………………………
Time: ……………………………………… Pain score (1-5): ………………………………
Discharge Time: ………………… Pain score (1-5): ……………. Bleeding: Yes / No
Comments: ………………………………………………………………………………………………
DISCHARGE ADVISE GIVEN: Yes / No Signed: …………………………………………
Woodbank surgery
2-Hunstanton Drive
Brandlesholme,
Bury: BL8 1EG
Consent Form
Parental agreement to the Circumcision operation for a child:
Baby’s Name: ………………………………………
Date of birth: ………………………………………..
Surgeon’s Name: …………………………………..
Name of proposed procedure: Circumcision for Religious / Cultural reasons
I have explained the procedure to the parent(s). In particular, I have explained:
The intended benefits: Religious & Cleanliness
Frequently occurring risks: 3% risks of post-op bleeding, infection and plastibell related issues or
any extra procedures for anaphylaxis & resuscitation which may become necessary during the
operation.
I have also explained what the procedure is likely to involve, the limits of the plastibell
procedure including the need to Re-do procedure at times for the possible undercut
foreskin, the options of any other available alternative procedure (including no treatment)
and any particular concerns, if raised by the parents.
Signed (GP) ………………….Date …………………Name: ………………………..Job Title: ………..
Statement of Parents:
Please read this form carefully. If you have any further questions, do ask, we are here to
help you and your child. You have the right to change your mind at any time, including after
you have signed this form.
I agree to the procedure or course of treatment described on this form and I confirm that I have
‘parental responsibility’ for this chid.
I confirm that I had the opportunity to discuss the details of anaesthesia with you before the
procedure, unless the urgency of the situation prevents this.
I understand that any procedure in addition to those described on this form will only be carried out
if it is necessary to save the life of my child or to prevent serious harm to his or her health.
I have been told about additional procedures which may become necessary during my child’s
treatment. I have listed below any procedures which I do not wish to be carried out without further
discussion.
Signed ………………………………………………….Date ………………………………………….
Name (PRINT) ………………………………………..Relationship to child ………………………..
Name (PRINT) …………………………………………Relationship to child ………………………..
Dr. Afzal Hussain
CIRCUMCISION FOLLOW UP
Date of Procedure ……………………………………………………………………
Patient Name …………………………………………………………………………
DOB……………………………………………………………………………………
Tel No: …………………………..............
Mother’s Name …………………………Father’s Name ………………….............
Telephone Follow up 1st Day Post Procedure
Date/Time ……………………………………………………………………………
1. How has your baby been?
Slightly irritable Yes No
Off Feeds Yes No
Slightly pyrexial (up to 37.5C) Yes No
Crying more than usual Yes No
2. Has there been any bleeding? Yes / No
What kind of bleeding Fresh Old
Has it clotted Yes No
How much in the nappy Small Large
Home visit required Yes No
Any other problems: …………………………………………………………………………
Dr / Nurse sig: ………………………………………………………………………..
Name: …………………………………………………………………..
Call received from parents on: ……………………………………………………….
Ring came off day: ………………………………………………………………
Any problems: ……………………………………………………………………
……………………………………………………………………..
Parental satisfaction: 1 2 3 4 5
Dr. Afzal Hussain
Telephone Follow Up: 10th Post –operative day
Date of circumcision …………………………………………………………………………
Condition of baby over the past week ………………………………………………………
…………………………………………………………………………………………………..
1. Pain Experience
None A little A lot How long? …………………………………
2. Has there been any other problem? Yes / No
If yes please explain: …………………………………………………………………………
…………………………………………………………………………………………………..
………………………………………………………………………………………………......
3. Has the plastibell fallen off? Yes / No
If Yes: Day ……………………………………………………………………………..
4. Are parents happy with overhaul experience: Yes / No
Comments: …………………………………………………………………….
……………………………………………………………………..
………………………………………………………………………
……………………………………………………………………..
Date: …………………… Name: …………………………. ….. Signature ……………………