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About
Procedures
Gallery
- Before & After Photos
- Video Gallery
Patient Resources
Out-of-Town Patients
Blog
Contact Us
Schedule Now

Home Breast and Vaginal History Form

Breast and Vaginal History Form

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Patient Name*

Today's Date*

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Breast History

What is your particular breast problem?*

Does this run in female members of your family?*

Yes

No

What is your height?*

What is your weight?*

What bra size do you wear?*

Padded or unpadded?*

Padded

Unpadded

What is your desired breast size?*

Write "I don't know" if not sure

How many children do you have?*

Ages?

Did your breasts change with pregnancy?*

Yes

No

Did you breastfeed?*

Yes

No

If no, was it by choice?*

Yes

No

History of breast disease or tumors?*

Yes

No

Have you ever had a mammogram?*

Yes

No

If yes, where and when?*

Have you ever had another breast surgery (reduction, enlargement, or lift)? *

Yes

No

If yes, list doctor and date:*

Have you ever experienced any of the following breast problems?

Nipple Discharge

Breast Lumps (or breast cysts)

Breast Trauma

Breast Infections (mastitis)

Inverted Nipples

Breast Pain or Swelling

Are you currently taking birth control pills or receiving estrogen shots?*

Yes

No

If you were treated for breast cancer, did you receive chemotherapy or radiation?*

Yes

No

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Office Phone:
480-951-4343

Via Fax:
480-970-3100

Via Email:
office@drmazaheri.com

480-951-4343

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Suite 100
Scottsdale, AZ 85254

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