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BRA FITTINGS
MASTECTOMY CARE
Mastectomy Bras
Breast Prostheses
Chemo Empowerment Solutions
Treatment Companion
SOCIAL IMPACT
Community Outreach
Schools Outreach
Teen Education
Comfort Matters Seminar Series
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Data Form
Data Form
Name
*
Address
Telephone Number
Email Address
Date of Birth
*
Current Bra Size
*
Challenges with your Bra
Strap
Band
Cups
Do you have any allergies to fabric ?
*
Have you ever done any breast surgery?
*
Was it:
Needs Aspiration
Biopsy
Mastectomy
Lumpectomy
Augmentation
Reduction
Implant
Which side breast ?
Left
Right
Both
Which breast is larger?
Right
Left
Date
How do you describe your breasts :
Firm
Supple
Heavy
Loose
Uneven
Rounded
Bongated
Pendulous
Have you had any pregnancies ?
Are you currently Pregnant?
If Yes, when dues?
Have you ever breast fed a baby?
Yes
No
How do describe your nipples?
Protruding
Flat
Inverted
Regular
Do you have pains in your :
Back
Neck
Shoulder
Feet
Do you have any plans of losing gaining weight?
Yes
No
If Yes, what is the duration of the programme?
Do you usually lose gain weight rapidly?
Yes
No
Do you have any special needs for a particular bra/ undergarment at present?
What is your favourite colour?
U:
M:
B:
Bra Size:
Date
Comments:
Recommendations:
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Name
Country/Area Code
Phone Number
Email
Date of Surgery
Post-Surgical
Everyday
Teen Fitting
Speaking Request
Please Describe The Job In Detail
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