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Name:______Clinic #:______Date:______

Breast Reduction (19318) Evaluation Form Dr. Faeza R. Kazmier

Please check all that apply. Do you overfill your bra? c Yes c No Are your sensate? c Yes c No I. What symptoms do you have? Is sensation important to you? c Yes c No c Large size Do large run in your family? c Yes c No c Shoulder pain c Neck pain III. c Upper back pain Do you suspect that you c irritation under your breasts may be pregnant? c Yes c No c Back spasms Method of contraception______c Hand tingling or numbness Have you ever been pregnant? c Yes c No c One breast is LARGER than the other one When was your last pregnancy?______c Right Did your breast size change? c Yes c No c Left Explain______c No difference Were you able to breast feed? c Yes c No c Grooving on your shoulders from bra straps When did you stop lactating?______c Have to wear more than one bra to Do you plan on get comfortable in the future? c Yes c No c Unable to sleep on back due to breast size c Decreased tolerance, or difficulty/inability IV. to exercise Do you perform self-breast exams? c Yes c No c Have to support breasts while walking, Have you ever had sitting, driving • Annual screening breast exam c Yes c No c Difficulty finding clothes that fit When was the last one and result?______c Self-conscious about your large breast size • Mammogram c Yes c No c Miss work because of breast/back/neck When was the last one and result?______problems • c Yes c No c Treated by a specialist for breast/back/neck When was the last one and result?______problems • Fibrocystic Breast disease c Yes c No c Take medications for neck/back problems When was the last one and result?______c Posture problems • Breast cancer c Yes c No c Other______Explain______How long have your had these symptoms? ______• Family member with breast cancer c Yes c No Explain______II. Breasts ______How tall are you?______• Do you have What bra size do you wear now?______Lumps or bumps in your breasts? c Yes c No What is your weight______lb/kg Explain______What bra size would you like to be?______Does your breast size change • Drainage from your nipples c Yes c No with weight loss? c Yes c No Explain______06 PS MR 103