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Date
|
Comments
|
|
Name
|
How did patient find the Doctor?
• • •
|
|
DOB
|
|
|
Chart Number
|
|
|
Current Cup Size
|
|
|
Desired Cup Size
|
|
|
Contemplating Procedure?
|
|
|
Pregnancies
|
|
|
Last pregnancy date
|
Ovaries
|
|
Patient has children
|
Comments
|
|
How many children?
• • •
|
|
|
Plan to have more children?
|
|
|
Why this procedure today?
|
|
|
Personal history of Breast CA
|
|
|
Mammogram Date/Findings
|
|
|
Biopsy Findings
|
|
|
|
|
|
Hospitalizations
|
|
|
Past Medical History
• • •
|
|
|
Cardiac Problems
|
|
|
|
|
|
Family History
• • •
|
|
|
Family History of breast cancer?
|
|
|
Mammogram
|
Assessment/Plan Comments
|
|
Previous Biopsy
|
Off label use
|
|
Abnormal Nipple Discharge
|
|
|
Breast Fed
|
|
|
Hysterectomy
|
Implant size suggested
|
|
Hyper-coagulable Disorders
|
Additional Vol. Rec
|
|
Recent Immobilization?
|
Client Preference (Right)
|
|
|
|
|
General History
• • •
|
|
|
Marital Status
|
|
|
Employed
|
Risks entail
|
|
Height
|
|
|
|
|
|
Turn on to start actual exam
|
|
|
Nipple
|
|
|
Bands
|
|
|
Larger Breast?
|
|
|
Est. Vol Diff: add CC
|
|
|
|
|
|
|
|
|
Assessment/Plan
• • •
|
|
|
Discussed Gel Implants
|
|
|
Silicone Gel Candidate
|
|
|
|
|
|
Treatment
• • •
|
|
|
Implant
• • •
|
|
|
Client Preference (Left)
|
|
|
Incision
• • •
|
|
|
Placement
• • •
|
|
|
|
|
|
Risks Discussed
• • •
|
|
|
|
|
|
Breast Diagram
|
|
|
|
|
|
BP before surgery
/
|
|
