KAROL A. GUTOWSKI, MD, FACS
AESTHETIC SURGERY
CERTIFIED BY THE AMERICAN BOARD OF PLASTIC SURGERY
MEMBER AMERICAN SOCIETY OF PLASTIC SURGEONS
Confidential Health Questionnaire for Breast Enhancement
Includes breast augmentation with implants or fat and breast lifts
Today's Date: _____________________________
Name ___________________________ Middle Name: ___________________________ Last Name: ____________________________
Age ____________ Date of Birth ____________________________ Gender: ____________ Email: _____________________________
Mailing address: _______________________________________ City: ____________ State: ____________ Zip Code: ______________
Allowed forms of communication: (By allowing communication via telephone, I permit Chicago Cosmetic Institute to leave voicemails
with persons other than myself)
Phone Number: _________________________________________
Other Phone Number: ___________________________________
Emergency Contact ______________________________________
Emergency Contact Phone Number: ________________________
Primary Care Physician ___________________________________
Phone Number: ________________________________________
Reason for visit ________________________________________________________________________________________________
Current bra size ________
Desired bra size ________
Have you had a mammogram?
If yes, please give date and result
Have you had a physician examine your breasts?
If yes, please give date and result
Do you perform a regular breast self exam?
If yes, have you found any abnormalities?
Have you had any problems with your breast?
If yes, please give date and details
Has anyone in your family had breast problems?
If yes, please give details
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
MEDICAL INFORMATION
Allergies □ None
□ Medications _____________________________
□ Environmental ___________________________
□ Latex
Reaction _______________________________________
Reaction _______________________________________
Reaction _______________________________________
Medications (including dietary supplements, nonprescription 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?
No
Yes
Packs per day ____________________________________
Year started ________Year stopped ___________
Do you drink alcohol?
No
Yes
Drinks per week __________________________
Do you use recreational drugs?
No
Yes
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 (if yes, please explain)
□ Thyroid disease
□ Easy bruising
□ Stomach or intestinal bleeding
□ Anemia
□ Asthma
□ Irregular or rapid heart beat
□ Arthritis
□ Varicose veins
□ High blood pressure
□ Cancer or tumor
□ Seizures
□ Frequent gum or nose bleeds
□ Diabetes mellitus
□ Palpitations
□ Angina or chest pain
□ Heart attack
□ Hepatitis
□ Jaundice or liver disease
□ Heart failure
□ Kidney disease
□ Heart murmurs
□ AIDS or HIV positive
□ Stroke
□ Shortness of breath or wheezing
How did you hear about our practice?
□ Internet search
□ Doctor
□ Television
□ Magazine
□ Hernia
□ Immune disorders
□ Fainting or dizziness
□ Nervous breakdown
□ Frequent heartburn or reflux
□ Mood disturbance
□ Stomach or duodenal ulcer
□ Friend
□ Other __________________
□ Web site _______________________________________
Who can we thank for this referral? ___________________________
Completed by ____________________________________________________
Signature ________________________________________________________
Section below to be completed by physician
Read & reviewed by Physician’s Signature _____________________________________________
Physical Exam: Height _______
Masses
Discharge
Skin tone

Ptosis
R L
Weight ______ lbs
Notch - Nipple
Nipple - IMF
Base width
Areolar width
Right
Left
Impression:
Recommendations:
Implant
Size
Incision
Pocket
□ Rice bag test
□ Bring images
□ Typical results reviewed
□ Mammogram
□ Informed consent
□ Second visit offered
□ Implant warrantee
□ 3D imaging done
Signature ________________________________________________________
Date ___________________
Location _____________________ Anesthesia ___________________ Time ______________ Position _______________________
Precautions ___________________ Blood _______________________ Equipment ________________________________________