Patient Information Form for Plastic Surgeons
Please fill this form out and present it to your surgeon at your consultation. This will give your surgeon a good idea of the results that you're looking for, as well as some important information about your personal health, family history of breast cancer, etc.
YOUR NAME:
______________________________________________________
Age ________
Height & Weight: __________________
Current Bra Size: __________________
Desired Bra Size: __________________
Preferred Incision Site: ______________
Exercise Activity Level: Light _____ Moderate ______ Bodybuilder (work chest muscles heavily) ______
I want a: Natural Look _____ Fake Look _____ Somewhere in between a natural and fake look _____
Breast Cancer Family History:
____ Yes ____ No / If Yes, fill in relative, and
be sure to include whether it is/was on the maternal or paternal side of your
family.
______________________________________________________________________________________________________________________________________________________________________________
I have breastfed ______ children for a total of _______ months / years. (circle the answer that applies to you)
I have brought before and after photos which show the size and "look" that I would like to achieve.