Breast Surgery Consultation Form
What a breast surgery consultation form asks, with sample questions on concerns, breast size, and breast history.
A breast surgery consultation form records the patient's concerns, breast size changes, breast history, pregnancies, medicines, and habits before a plastic surgery consultation. Kaiser Permanente's Santa Rosa plastic surgery department calls its version a breast surgery patient information worksheet.
Breast surgery consultation form, handled by the AI Doctor avatar
AI Doctor, a real-time AI healthcare assistant avatar, asks the questions on a breast surgery consultation form in the patient's own language, strictly following the practice's instructions.
- Intake before the visit. Patients answer online before they arrive, or at a kiosk when they check in.
- Answers ready for the clinician. Clinicians see what the patient said before the visit starts.
- Less workload at the front desk. Staff spend less time handing out forms and entering answers by hand.
- Key details at a glance. The care team sees what matters up front and decides who needs attention first.
The form becomes a natural conversation: patients answer by talking, in their own words. AI Doctor is an information and patient-assistance interface. It collects answers for the care team to review. It doesn't diagnose, triage, or give treatment advice.
Sample breast surgery consultation form questions
Typical questions, written out so you can see the level of detail. Every practice words its own form differently.
- Which symptoms or concerns bring you in?Concerns
- What do you hope this surgery will achieve?Concerns
- How does weight change affect your breast size?Breast size
- What is your largest and smallest cup size?Breast size
- Has anyone in your family had breast cancer?Breast history
- Which breast surgeries have you had before?Breast history
- Have you been pregnant, and how many times?Pregnancies
- Did you breastfeed, and for how long?Pregnancies
- Have you taken cortisone or steroids?Medicines
- Have you taken hormones, including birth control?Medicines
- Do you use tobacco, and how much?Habits
- Do you use alcohol or other drugs?Habits
These are examples to read, not a form to fill in.
Breast surgery consultation form: FAQ
What does a breast surgery consultation form ask?
The sample questions on this page are based on Kaiser Permanente's breast surgery patient worksheet. This page groups them into six areas: concerns, breast size, breast history, pregnancies, medicines, and habits.
Who fills in a breast surgery consultation form?
The patient. Kaiser Permanente's worksheet serves several breast procedures, with sections on implant revision and cancer reconstruction marked 'if applicable'.
Does it ask about breast cancer history?
Yes. Kaiser Permanente's worksheet asks about past breast disease, cancer, or biopsies, family history of breast cancer, and the date of the last mammogram.
Does it ask about pregnancy and breastfeeding?
Yes. Kaiser Permanente's worksheet asks whether the patient has been pregnant and how many times, and whether they breastfed, for how long, and how many times.
Is there a breast surgery consultation form template?
The sample questions on this page show a typical set. Kaiser Permanente's worksheet is a five-page version.
What happens after the form is completed?
The surgeon goes over the answers with the patient at the consultation. The worksheet also asks which questions the patient wants answered.
Does AI Doctor give medical advice?
No. It collects information for the care team. It doesn't diagnose, triage, or recommend treatment.
Can patient answers stay on our own servers?
Yes. RAVATAR offers on-prem deployment: the platform can run inside your own perimeter, so patient answers stay there. RAVATAR complies with GDPR and the EU AI Act.
Set up your AI Doctor in Genesis AI Avatar Studio
Genesis AI Avatar Studio is where you set up, test, and publish AI avatars for your website, mobile app, or Holobox. No coding or technical skills needed.
- 01Choose the AI Doctor avatar.
- 02Add your practice's FAQs and visit information.
- 03Talk to it, then publish it.
