Breast Self-Assessment Form – (BREAST surgery patients to complete)

Breast Self-Assessment Form

    Please note that your information is saved on our server as you enter it.

    BREAST AUGMENTATION, LIFT OR REDUCTION

    For patient to completeThinking of your breasts in the past week, please tick the circle that indicates how satisfied or dissatisfied have you been with:


    How your breasts look when clothed:*

    • very dissatisfied

    • somewhat satisfied

    • very satisfied

    How your breasts look when unclothed:*

    • very dissatisfied

    • somewhat satisfied

    • very satisfied

    The size of your breasts:*

    • very dissatisfied

    • somewhat satisfied

    • very satisfied

    The shape or symmetry of your breasts:*

    • very dissatisfied

    • somewhat satisfied

    • very satisfied

    Current size*

    Goal cup size (please note a specific cup size cannot be guaranteed)*

    What asymmetries do you notice about your breasts (nipples, breast fold height, size etc)*

    Goal breast appearance (please tick whichever applies)*


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    3181

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