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Please answer all questions |
| Patient Name: |
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| E-mail Address: |
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| Phone Number: |
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| 1. Please indicate how much weight you have lost over the past 2 years. |
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| a. How much did you weigh prior to loosing weight? |
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b. What is your current height, and weight (lbs.)?
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| b. Do you anticipate any further weight loss? If so, how many (lbs.) and by what date? |
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| c. By what method do you anticipate further weight loss? |
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| d. Do you have any body contouring surgery scheduled elsewhere? If so what date? |
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| e. Name, Address, and Telephone number of your bariatric surgeon. Please indicate if you have had any post surgical complications, hernia, etc. |
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| f. Please provide a list of personal physicians including their Address, and Telephone Number. And indicate your primary care giver or specialist. |
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| g. Have you experienced Comorbidities prior to your recent weight loss? (Push your CTRL key to select additional choices. Macintosh users press your Apple key.) |
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| h. Have you experienced Comorbidities after bypass surgery? (Push your CTRL key to select additional choices. Macintosh users press your Apple key.) |
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| i. Do you have any other significant medical or psychiatric conditions? |
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| 2. Your body contour concerns and priorities. Please check your specific areas of interest. |
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Liposuction |
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W/ Breast Augmentation |
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W/ Breast Reduction |
| a. Please select your interests in improving body features and rank them in numerical order (with 1 being the most important). |
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| 3. Have you had any prior body contouring surgery? |
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Liposuction |
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Excisonal Surgery |
| a. In what areas was your prior surgery concentrated on? |
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Face, Neck |
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Arms |
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Breasts |
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Abdomen, Hips |
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Back Flanks, Pubic Region, Buttocks |
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Outer Thighs |
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Inner Thighs |
b. Were you satisfied with the results
of your prior surgery? |
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| c. Have you considered or started the process of legal claims for damages for prior operations? |
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| d. Please specify the location of any significant scars that you may have. |
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Face, Neck |
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Arms |
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Breasts |
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Abdomen, Hips |
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Back Flanks, Pubic Region, Buttocks |
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Outer Thighs |
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Inner Thighs |
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None |
| e. Are you considering surgery by Dr. Hurwitz? |
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Yes |
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No |
| f. Please send any photos of yourself that you think would be helpful. |
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| 4. Do you have any further questions or concerns regarding surgery and procedures? |
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