checklist for breast augmentation by fat transfer

NAME:

AGE:

BRA INFORMATION

• Current bra size ______
• Desired bra size ______

WOULD YOU CONSIDER IMPLANT AUGMENTATION?  Y  /  N  / MAYBE

PREGNANCY INFORMATION

• Pregnancies?  Y   /   N
  • Number of children ______
  • Did you breastfeed?  Y  /  N
    • For how long? _____________
  • Do you plan on children in the future? Y  / N

WEIGHT INFORMATION

• Height _______ft ________inches
• Weight _________pounds
  • how much has your weight fluctuated in the last year? from ________ to _________
  • have you had any weight changes more than 20 pounds? Y  /  N
  • maximum weight pregnant _________
  • maximum weight non pregnant __________
• How much do you exercise weekly on a regular basis?   ___________________________
• BMI ___________   BMI CALCULATOR LOCATED HERE
• Where is your largest fat pocket located?
  • abdomen
  • inner thigh
  • outer thigh
  • love handle
  • other
• Have you had prior liposuction?   Y  /  N

HEALTH INFORMATION

• Do you have a history of:
  • Diabetes?
  • Smoking?
    • never
    • socially
    • current smoker   ______packs / day for ________years
    • ex smoker _______packs/day for _________years.  QUIT: ______yrs ago
    • smoke something other than cigarettes?  (includes ecig, nicorette gum, marijuana, cloves)
  • High blood pressure?
  • High cholesterol?
  • Anemia?

BREAST IMAGING & CANCER INFORMATION

• Have you had a mammogram?   Y   /  N
  • date of last mammogram ___________
    • any abnormalities?
    • history of biopsy?
    • told have “hard to image” “fibrocystic” or “dense breasts”?
  • any family history of breast cancer?   Y  /  N
    • mother aunt sister grandmother
    • personal history of breast cancer  Y  /  N
    • cancer at age before menopause  /  after menopause
    • BRCA positive status?  Y   /   N   /  never tested
  • have you ultrasound or MRI image of the breasts?   Y   /   N