Breast Reconstruction 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
Breast Surgeon
Radiation Oncologist
Oncologist
Other Doctors
Number of Births
Do you breast feed?
*
Yes
No
Last mammogram date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What was the result?
*
Have you had any other breast or abdominal procedures? If so, can you provide dates?
*
Reasons for seeking breast reconstruction
*
Considering Mastectomy
Had a Mastectomy in the past
Considering Lumpectomy
Had a Lumpectomy in the past
Correct long withstanding deformity
Problems with breast implants
Have you talked to anyone else who has undergone breast reconstruction?
*
Yes
No
If not would this be helpful to you?
*
Yes
No
Are you most interested in reconstruction using your:
*
Your Own Tissue
Implants
Unsure
What would you like your reconstructed breasts to be
*
The same size as now
Smaller
Larger
Unsure
Would you consider surgery on your opposite breast to achieve better symmetry?
*
Yes
No
Unsure
Submit
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