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HRUS Scan of Silicone Gel Breast Implants (#4)
TO BE COMPLETED BY ULTRASOUND TECHNICIAN
All suspected ruptures require images & video to send for confirmation by the Ultrasound Consultant
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1.
STUDY SITE NUMBER: (enter the assigned number for your site)
(Required.)
2.
Subject Initials (Two Characters)
(Required.)
3.
Confidential Subject ID (3 Numbers)
(Required.)
4.
Scan Completed by (Last Name)
(Required.)
Note Diagram Before Continuing
5.
Was a radial scan of all 4 quadrants performed for each breast implant?
(Required.)
Yes, Only Right Breast Scanned
Yes, Only Left Breast Scanned
Yes, Both Breasts Scanned
Subject Not Scanned, notes below
6.
Was an implant rupture detected?
(Required.)
No – Provide any notes, validate and provide subject with Post-Scan Survey, CRF #5a
Yes – Indicate suspected rupture location in next section
Current Progress,
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