THIS FORM IS TO BE COMPLETED BY THE SUBJECT IF THERE IS A SUSPECTED RUPTURE OF AN IMPLANT 

This survey is designed to learn how you feel about possible silent rupture of your silicone gel breast implants after learning the results of the ultrasound scan. Questions refer only to your current silicone gel implants, not any implants you may have had previously. Check one answer for each question, unless otherwise indicated.

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1. As your ultrasound scan showed an implant rupture, which of the statements below apply to you? (check all that apply)

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2. Would you like to revmove the ruptured implant, even if not causing symptoms?

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3. What would prevent you from removing the ruptured implant? (check all that apply)

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4. Which course of action are you most likely to take?

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5. If you choose to replace your ruptured implant, when would you want it replaced?

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6. If you were getting breast implants for the first time today, which of the 3 different implant types would you consider? (check all options that you would consider)

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