INITIAL BRAVA EVALUATION 

Print the evaluation form, fill out form, sign and mail to: 

Dr. Walter A. Dobson
Dallas-Fort Worth Institute of Body Sculpturing
647 S. Great Southwest Parkway
Grand Prairie, TX 75051 

PATIENT NAME: ____________________________________ DATE: __________________

CURRENT BRA SIZE:____________________ PATIENT DESIRES: __________________

RACE: ______________________________________________________________________

HOW MANY CHILDREN HAVE YOU HAD? ______________________________________

ARE YOU TAKING ORAL CONTRACEPTIVES? ______ NAME? ___________________

MAMMOGRAM HISTORY: 

HAVE YOU HAD A MAMMOGRAM?     NO ____   YES ____

DATE: ______________ WAS IT NEGATIVE? _________

Please send copy of report.  If you have not had a recent mammogram, then one may be required.  
If a mammogram is not available in your area, a manual exam will be required.  

DO YOU HAVE ALLERGIES OR ARE YOU HYPERSENSITIVE TO SILICONE BASED OR ADHESIVE PRODUCTS?
_________________________________________________________________

DOES YOUR SKIN KELOID?
_________________________________________________________________

ARE YOU PREGNANT? ______________________________________________

MEASUREMENTS

HEIGHT: _____’___” WEIGHT: _______LBS.

CHEST WALL MEASUREMENTS (UNDER YOUR BREASTS): _______” 

BREASTS MEASUREMENTS (AROUND YOUR BREASTS): __________”

JOG BRA SIZE: SMALL ___ MEDIUM ___ LARGE ___

THIS INFORMATION IS ACCURATE AND TRUE TO THE BEST OF MY KNOWLEDGE. 

PATIENT SIGNATURE ______________________________ DATE ___________________