Abdominoplasty Questionnaire
Please fill out the following questions prior to your abdominoplasty/panniculectomy consult.
Patient Name
*
First Name
Last Name
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If you have been referred by your family physician, please state his/her name:
Current Height
*
Current Weight
*
Is this a stable weight for you?
*
Yes
No
If not, how much weight have you gained or lost in the last 6 months?
Do you attribute any medical problems to excess abdominal tissue?
*
Yes
No
Have you had treatment for any of these problems before?
*
Yes
No
If yes, what was the treatment?
Have you had any pregnancies?
Yes
No
Have you had any abdominal surgeries?
*
Yes
No
List any abdominal surgeries you've had.
Are you taking any prescription diet medication?
*
Yes
No
If yes, what is the medication? Who prescribed the medication?
Have you talked with any friends or family who have had this surgery before? *
*
Yes
No
By signing this form you give permission to Lawrence Plastic Surgery to release this information to your insurance company if pre-authorization of proposed treatment is required.
Submit
Should be Empty: