Breast Implant Illness Survey: Please participate and share this survey IF you currently have or used to have breast implants.
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  • PLEASE complete and share this survey if you've ever had breast implants!!

    If you have ever had breast implants or currently have breast implants, please help us complete our research with this quick survey. We do not require any personal data for completion of this survey. There is an option at the end of the survey to submit your email which is 100% optional if you would like to be contacted with the results and/or other related information. The best way for us to get remarkable data is via participation. We ask those who've ever had breast implants regardless of when, how long, with or without complications to complete. PLEASE SHARE!! 

  • *

    We are committed to providing excellent care and services to our clients. By participating in this survey, you are agreeing to answer all questions honestly and to the best of your knowledge. Your participation in this survey is only relevant if you currently have or have had breast implants. Do you currently have or have you had breast implants in your past?


    If you answered NO, there is no need to further complete the survey. 

  • *What is your age?
  • *At what age did you have your breast implant surgery?
  • *How many years have you had (or did you have prior to explanting) breast implants? (i.e. total number of years-if less than one year, please indicate the number of months followed by mos. to clarify months)
  • *Please select the brand of breast implants you have.
  • *

    Please select the type of implants you have: 

    **You must select the

    1. type of shell (textured or smooth),  

    2. the shape (round or anatomical),

    3. and the fill (Saline or Silicone)** for 3 total selections. 

  • *

    PRIOR TO GETTING IMPLANTS:

    Did you suffer any of the below symptoms PRIOR TO GETTING IMPLANTS? Select symptoms based on recurrent only, (not an isolated, one-time symptom). Please select all that apply:

  • *

    CURRENTLY HAVE IMPLANTS:  

    Do you currently suffer any of the below symptoms? Select symptoms based on recurrent only, (not an isolated, one-time symptom). Please select all that apply ONLY if you currently have implants: (select none of the above if you  do not currently have implants)

  • *

    YOU HAVE HAD EXPLANT SURGERY-

    Please Mark YOUR SYMPTOMS WHILE YOU HAD IMPLANTS-NOT CURRENTLY:


    Did you suffer any of the below symptoms before explanting? Select symptoms based on recurrent only, (not an isolated, one-time symptom). Please select all that apply ONLY if you have had EXPLANT surgery and suffered any of these symptoms while having implants prior to explanting. (i.e. only select symptoms that were prior to the explant surgery while you had implants but not current symptoms if applicable)

    If you have not had explant surgery, select the box that states: this question does not apply as I have not had explant surgery. 

  • *

    YOU HAVE HAD EXPLANT SURGERY-CURRENT SYMPTOMS:

    Do you currently suffer any of the below symptoms? Select symptoms based on recurrent only, (not an isolated, one-time symptom). Please select all that apply ONLY if you have had EXPLANT surgery.

    If you have not had explant surgery, select the box that states: this question does not apply as I have not had explant surgery. 

  • *Do you have a known family history of any of the symptoms listed above? 
  • *Have your symptoms (if any) interfered with your ability to perform daily tasks? 
  • *

    At what age were you when one or more of these symptoms began? 

    (Please enter "0" if this doesn't apply to you, i.e. you've never had any of these symptoms) 

  • *Did you take any supplements, over-the-counter, or prescription medications prior to the onset of the symptoms listed above? 
  • *Have you ever had a mammogram? 
  • *

    Have you ever had any other diagnostic tests (non-mammogram) of your breasts?

    If no, please indicate: N/A

    If so, please list: 

  • *Do you have any biological children? 
  • *

    What was your age when you birthed your first child? 

    If you have not given birth please enter 0. 

  • *Have you experienced full menopause? (the absence of a period for 12 months)
  • *Have you experienced perimenopause and if yes-been tested for estrogen levels with lab confirmation?
  • Please list your email if you would like to be contacted with the results of this survey and/or future information related to breast surgeries/recovering from breast surgeries.
  • Please use this space to share any information you would like. You can contact us at: info@TheChrysalisMethod.com if you have any questions or would like more information about this survey and/or The Chrysalis Method

That's all, folks!

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