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