We ndy R. Gottlie b M.D., P.L.C.
Plastic and Reconstructive Surgery
Breast Reduction Questionnaire
Name:________________________________DOB____________MR#_____
What are your symptoms related to your breasts? (Please check all that apply)
Height ____________ Weight _______________ Bra size ________________
_____Breast pain
______Lower back pain
______Rashes
_____Shoulder grooving
_____Mid back pain
______Neck pain
_____Upper back pain
_____Shoulder pain
______Headaches
_____Limitation of activity
Other: _______________________________________________________
How long have you experienced these symptoms? __________________________
Have you had any previous treatment? _________________________________
Have you seen you primary doctor for this problem? ________________________
Do you wear specialty/support bras? __________________________________
How often you exercise? Type? ______________________________________
Have you taken any prescription drugs relating to you your symptoms? ___________
Which prescriptions? _____________________________________________
Did this help? _________ Complete relief / moderate relief/ minimal relief/ no relief
Have you taken any over the counter medications for this problem? ______________
Which medications? ______________________________________________
Did this help? _____ complete relief / moderate relief/minimal relief/ no relief _____
Have you seen a physical therapist? _________If so, was this helpful?____________
Have you seen a chiropractor? _____________If so, was this helpful? ___________
Height ____________ Weight _______________ Bra size ________________
Number of Children: ________ ages: ______Did you breast feed? ____________
Are you planning additional pregnancies? ________________________________
Have you seen anyone else for this problem? ______________________________
Any family history of breast cancer or breast disease? ________________________
Have you had any breast lumps, masses or cysts? ___________________________
Have you have had breast cancer? _____________________________________
When was your last mammogram? _______________ Was it normal? __________
--------------------------------------------------------------------------------------------------------(Below is for office use only)
___Masses/LAD
___Skin Tone
_____BSA Calculated
____Schnur
___Ptosis Grade I/II/III
___Asymmetry
___Inframammary skin
___Grooving
___Lateral Chest wall
Estimated grams of tissue to be removed: Right ___________ Left ____________
1800 Town Center Parkway  Suite 418  Reston, Virginia 20190
703.668.9499 phone  703.689.4998 fax