James E Vogel, M.D.
4 Park Center Court, Suite 100
Owings Mills, Maryland 21117
(410) 484-8860

BREAST QUESTIONAIRE

Patients Name: _________________________________________

Age: ________________ DOB: ________________



1. Your Height? __________ Weight? __________

2. What size bra do you wear? __________

3. What size would you like to be? ___________

4. How many children do you have? __________ Ages? ___________

5. Breast feed? ______Yes ______No How many children? _________

6. Did your breast change size with pregnancy? ______Yes ______ No

7. If yes, how much in bra size? _______________________________

8. Have you ever had a mammogram? ________ Yes _________ No

9. If yes, when? ____________________________________________

10. Any breast disease or tumors? _____________________________

11. If yes, explain? _________________________________________

12. Has anyone in your family had any breast diseases or tumors? _____ Yes _____No

13. If yes, explain? _________________________________________

14. Are you using any form of birth control? _______Yes _________No

15. If yes what form? _______________________________________



INFORMATION BELOW TO BE FILLED OUT BY OFFICE ONLY

NEEDS PRE-OP MAMMOGRAM____________YES ______________No