Breast Enhancement 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
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?
Have you had previous breast surgery?
*
Do you have a family history of breast cancer?
*
Yes
No
If yes, who?
Mother
Maternal Grandmother
Maternal Aunts
Sister
Have you talked with other women who have undergone breast augmentation? *
*
Yes
No
Have you consulted other sources (books, magazines, internet, etc.) to find out about breast augmentation? *
*
Yes
No
How long have you considered breast augmentation?
*
What else would you like to change about the appearance of your breasts?
*
What is your desired bra size?
*
Submit
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