Breast Reduction Questionnaire (Page 2 of 2) in pdf

Have you had any previous breast surgery? Yes ____ No ____

Type

Date

Results

Do you have any family history of breast cancer? Yes ____ No ____

Relationship

Approximate age ______ Status

How many children do you have? _______

Did you breast feed them? Yes ____ No ____

If yes, how long?

Do you smoke cigarettes? Yes ____ No ____

Number of packs per day

Do you take aspirin or aspirin-containing products? Yes ____ No ____

Do you take steroids? Yes ____ No ____

Do you scar poorly? Yes ____ No ____

Do you have diabetes? Yes ____ No ____

Do you have high blood pressure? Yes____ No____

Are you being treated for any autoimmune disorder? Yes ____ No ____

Are you presently under the care of a physician? Yes ____ No ____

Do you have difficulty healing wounds? Yes ____ No ____

What is your highest and lowest weight in the last 12 months?

Most breast reduction surgery is covered by health insurance policies. The insurance

companies require written reports from our office before making the determination.

This report will contain information you have provided on this form and the results of

your examination. Polaroid photographs of your breast, and not your face, will also be

taken and sent along with this report. It is entirely your choice if you would like us to

prepare such a written report for pre-determination of your benefits. The complimentary

cosmetic consultation Does Not Cover the costs associated with insurance preparation

pre-determination and billing. Your insurance company will be billed if you ask us to

prepare this report, which includes, the photos, the fax, the follow-up, the FedEx, etc.

Do you wish this office to prepare as insurance pre-determination report for payment of

your breast reduction surgery? Yes ____ No ____

Do we have permission to send photographs of your breast (without your face) to your

insurance company? Yes ____ No ____

**If you answered “yes” to the 2 questions above, please provide us with an

insurance card or copy of your insurance information. **

YOUR INSURANCE COMPANY WILL BE BILLED FOR PREPARATION OF THIS

REPORT AND THE PHOTOS.

Signature

Date

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

Breast Reduction Questionnaire Page 2