Breast Reduction Questionnaire printable pdf download

BREAST REDUCTION QUESTIONNAIRE

Name

Age

Do you have any of the following: (Please check)

___Breast pain ....................................................... 611.1

___Shoulder pain.................................................... 723.9

___Neck pain.......................................................... 723.1

___Upper back pain................................................ 724.1

___Lower back pain................................................ 724.2

___Rash beneath your breasts................................ 695.89

___Finger or hand numbness.................................. 354.2

___Bra strap indentation..........................................

___Breast asymmetry.............................................. 611.8

___Nipple discharge.................................................

___Difficulty examining your breast..........................

___Fibrocystic breasts............................................. 610.0

___Breast masses................................................... 611.72

___Poor posture.......................................................

Do you have difficulty finding properly fitting clothing as a result of your large breasts?

Yes____ No____

Do you have to limit your physical activities as a result of your large breast size?

Yes ____ No ____

Have you seen a physician, surgeon or chiropractor for treatment of back pain of

problems related to your large breasts? Yes ____ No ____

Are you self-conscious about the size of your breast? Yes ____ No ____

How tall are you?

How much do you weigh?

Largest bra size _______________

How long have you considered reducing the size of your breasts?

Have any of your family members or friends undergone breast reduction surgery?

Yes ____ No ____

Relationship?

When?

Where?

By whom?

Were they satisfied? Yes ____ No ____

Did they experience any problems? Yes ____ No ____

What kind of problems?

Do large breast run in your family? Yes ____ No ____

Date of your last menstrual period: _________________

Do your breast change in size around the time of your period? Yes ____ No ____

Do you practice monthly breast self-examinations? Yes ____ No ____

What was the date of your last mammogram? ____________ Results

I:\Projects\MPS\Forms\New Patient Forms - April 2011\BBR Questionnaire-2010.DOC-9/17/01

Breast Reduction Questionnaire