breast-surgery-formHome > Breast Surgery FormName:*BREAST AUGMENTATION, LIFT OR REDUCTIONFor 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:* 1 2 3 4 5 6 7 8 9 10very dissatisfied somewhat satisfied very satisfiedHow your breasts look when unclothed:* 1 2 3 4 5 6 7 8 9 10very dissatisfied somewhat satisfied very satisfiedThe size of your breasts:* 1 2 3 4 5 6 7 8 9 10very dissatisfied somewhat satisfied very satisfiedThe shape or symmetry of your breasts:* 1 2 3 4 5 6 7 8 9 10very dissatisfied somewhat satisfied very satisfiedCurrent 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)* I want my breasts to be a little larger I want my breast to look a lot larger I want my breasts to look natural I want my breasts to look obviously augmented I want my breasts to sit high on my chest I want lots of upper pole fullness I want my breasts to sit in a natural position on my chest I want lots of cleavage I want lots of side breastThank You!
