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ID#
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Surgery Side
• • •
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Surgery Type
• • •
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Surgery Date
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Revision Date
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Prosthesis Type
• • •
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If "other" chosen, pz comment
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Age of Current Prosthesis
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General Condition
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Garment
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Size
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Breast Prosthesis
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Color
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Shape
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Side
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Attachment
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Nipple
• • •
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If "other" chose, plz comment
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Skin
• • •
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Surgical Healed
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Drains
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Touch Sensitivity
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Keloid
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Previous Prosthetic Experience
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Difficulties with Hands
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Current Chemo/Radiation
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Measurements Taken
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Diagnosed with Lymphedema
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Difficulties with ROM
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Care instruction given
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Measurements & Landmarks
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