The Center for Microsurgical Breast Reconstruction Are You a Candidate for Breast Reconstruction?  





Candidate for Breast Reconstruction

Your Status
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Select Your Current Situation:

On Which Side was Your Mastectomy:

Have you had Previous Reconstruction:
Yes  No

If Yes, What Type:

About You (Please do not use quotes or apostrophes. Use hyphens)
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Your Height: (example 5-5)

Marital Status:
Married  Single Divorced 

Your Weight:

# of Children:

Occupation:

Bra Size:

Date of Birth:
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Do You Drink Alcohol?

Do You Smoke?
Yes No Yes    No   

If Yes, How Much:

If Yes, How Much:

Your Contact Information (*Denotes Required Fields)
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First Name:*

Last Name:*
Email:*
Address:*
City:*
State:*
Zip:*
Home Phone:*
Work Phone:
Cell Phone:
Fax:

Do You Have Any Allergies/ Medications?
Please List Any Allergies:

Please List All Medication:
(including over the counter drugs, vitamins, & herbal supplements)



Medical History

Please Check All that Apply:
Heart Disease
Hypertension
Diabetes
Kidney Disease
Asthma
Cancer
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Have You Had Past Surgeries?
Yes    No  
  If Yes, Please Explain:
 
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Any previous problems with general anesthesia?
Yes    No    
  If Yes, Please Explain:
 

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Any previous complications from chemotherapy or radiation?
Yes    No     
  If Yes, Please Explain and Let Us Know When Your Last Treatment Was Completed:
 
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Is there a history of ovarian cancer in your family?
Yes    No     
  If Yes, Please Explain:




   

Miscellaneous
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How Would You Like Us to Initially Contact You?
Home Phone Work Phone Cell Phone E-Mail

Who is Your Insurance Carrier?

How Did You Find Us?

Please Specify if you've found us in a Chatroom or through Another Doctor:

Do You Have Any Comments?


 
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