Breast Reduction Questionnaire
Please fill out this form completely.
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
Current Height
*
Current Weight
*
Current Bra Size
*
Primary Doctor
Have you given birth?
Yes
No
Number of births you've had.
Do you currently breast feed?
Yes
No
Are you planning on having any more children?
Yes
No
Have you had a mammogram before?
*
Yes
No
Last mammogram date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What was the result?
Previous Breast Procedure
What problem(s) do you think are being caused by your large breasts?
Upper back pain
Neck pain
Shoulder pain
Lower back pain
Headache
Shoulder strap grooving
Poor posture
Rashes
Difficulties with exercise
Difficulties with work activities
Breast pain
Social embarrassment
Other
What have you done to try to relieve your symptoms?
Medication
Physical therapy
Shoulder pain
Chiropractic manipulation
Massage therapy
Special bras
Other
What prompted you to consider breast reduction surgery?
Suggested by my doctor or nurse practitioner
Talked with other breast reduction patients
Information I read or saw on TV, internet
Suggested by friend/relative
Other
Do you have a family history of breast cancer?
*
Yes
No
If yes, who?
Mother
Maternal Grandmother
Maternal Aunts
Sister
Other
What is your desired bra size?
*
Submit
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