Breast Reconstruction Questionnaire

Breast Reconstruction Questionnaire

Please fill out this form completely.
Patient Name *

First Name Last Name
Today's Date

Month Day Year
Date
Date of Birth

Month Day 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
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
Should be Empty: