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BREAST TREATMENT CONSULTATION:
Accurate prognostic for breast treatment.
Name: First ---------------------------------
Name: Last --------------------------------- Height ----------------------------------------
Weight --------------------------------------- Number children ---------------------------
Ages ------------------------------------------- Breast feeding: Yes --------- No --------
Menstruation: Normal ------------------- Irregular ------------------------------------- What age? ----------------------------------- Menopause? Yes ---------- No ----------
If yes, age ----------------------------------
birth control pill?Yes -------No ---------
Taken previously? Yes ------- No ----- at what age? ------------------------------- Number of years --------------------------
Have you ever been treated for a
tumor or a growth?
Yes -----------------------No ----------------
How long ago have you had your last
mammography? ----------------------------
Do you have breast implants?
Yes ------------------- No ------------------- Have you ever had breast surgery?
Yes ------------ No -------------------------- Do you regularly self-examine your
breasts? Yes --------- No ----------------
Have you ever suspected any anomaly?
Yes -------- No ----------------------------
BUST TYPE:
Sagging --------------------------------------
Atrophia (too small) -----------------------
Hypertrophia (too large) -----------------
Products used previously: --------------
------------------------------------------------- ------------------------------------------------- Comments: ---------------------------------
----------------------------------------------- ---------------------------------------------------
PLEASE NOTE THAT ALL INFORMATION HEREIN WILL BE KEPT STRICTLY CONFIDENTIAL AND IS NECESSARY IN ORDER TO GIVE YOU THE MOST ACCURATE PROGNOSTIC FOR THE RESULT OF THE TREATMENT (ESPECIALLY WHEN IT COMES TO BREAST DEVELOPPEMENT).
Please note: The products will only increase your breasts according to your body frame, in other words to the size you would have if your breasts had fully developed naturally at puberty.
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