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 OK Question Title 1. STUDY SITE NUMBER: (enter the assigned number for your site) OK Question Title 2. Subject Initials (Two Characters) OK Question Title 3. Confidential Subject ID (3 Numbers) OK Question Title 4. Scan Completed by (Last Name) OK Question Title Note Diagram Before Continuing OK Question Title 5. Was a radial scan of all 4 quadrants performed for each breast implant? Yes, Only Right Breast Scanned Yes, Only Left Breast Scanned Yes, Both Breasts Scanned Subject Not Scanned, notes below OK Question Title 6. Was an implant rupture detected? No – Provide any notes, validate and provide subject with Post-Scan Survey, CRF #5a Yes – Indicate suspected rupture location in next section OK NEXT