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Breast Enhancement Questionnaire

First name

Surname

Age

Date of birth

Email

Telephone number

Emergency contact name

Telephone number

Current bra size

Desired bra size

Desired Implants

Round Shape Teardrop Shape (natural shape)

Your height (in cm)

Your weight (in kg)

Have you had a mammogram?

Yes No

If yes, please give date and result

Have you had a physician examine your breasts?

Yes No

If yes, please give date and result

Do you perform a regular breast self exam?

Yes No

If yes, have you found any abnormalities?

Have you had any problems with your breast?

Yes No

If yes, please give date and details

Has anyone in your family had breast problems?

Yes No

If yes, please give details

Medical Information

Allergies

None Medications Environmental Latex

Reactions

Medications (including dietary supplements, non-prescription and herbal products)

Past Medical History (list any past or current medical problems, procedures or injuries, and operations, including complications)

Social History

Current occupation

Do you smoke or use tobacco?

Yes No

Packs per day

Year started

Year stopped

Do you drink alcohol?

Yes No

Drinks per week

Do you use recreational drugs?

Yes No

Details

Marital status

Married Single Widowed

Number of children

Will any dependents rely on you after surgery?

Are you planning on having more children?

Do you plan on breast feeding in the future?

Who will care for you after surgery?

Family Medical History (please explain if any of these conditions have affected a blood relative)

Cancer Breast Disease Heart disease (heart attacks, heart bypass surgery) Abnormal reaction to anesthesia

Bleeding or Blood Clotting Disorders

Have you or any blood relative had problems with:

Abnormal or excessive bleeding Abnormal or excessive blood clotting, also called Deep Venous Thrombosis (DVT) or Pulmonary Emboli (PE)

Do you have now, or have you been diagnosed as having

Stroke Thyroid disease Anemia Arthritis Cancer or tumor Diabetes mellitus Heart attack Heart failure Kidney disease Easy bruising Asthma Varicose veins Seizures Palpitations Hepatitis Stomach or duodenal ulcer Stomach or intestinal bleeding Irregular or rapid heart beat  High blood pressure  Frequent gum or nose bleeds  Angina or chest pain  Jaundice or liver disease  Mood disturbance  Heart murmurs  Shortness of breath or wheezing Frequent heartburn or reflux  Fainting or dizziness  Nervous breakdown  AIDS or HIV positive  Immune disorders

Images

Can you please attach images of your breasts. We need to see front elevation, and from both sides.

Front (both breasts)

Left side profile

Right side profile

Terms of acceptance

I agree to Surgio Medical's Terms and conditions, I have read the Privacy policy and I agree that my given details including health data may be processed by Surgio Medical for the purpose of obtaining quotes. This includes the transfer of my data to healthcare providers within and outside the EU. The consent can be revoked at any time with effect for the future.