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3-Month Post Scan Telephone Survey (#6)
THIS FORM WILL BE COMPLETED VIA TELEPHONE WITH SUBJECTS WHO HAD A SUSPECTED RUPTURE BASED ON SCAN
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1.
STUDY SITE NUMBER: (enter the assigned number for your site)
(Required.)
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2.
Subject Initials (2 characters)
(Required.)
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3.
Confidential Subject ID (3 Numbers)
(Required.)
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4.
Interviewer Last Name
(Required.)
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5.
Since your ultrasound scan about 3 months ago showed a
suspected
rupture of your implant(s), what action (if any) have you taken?
(check all that apply)
(Required.)
I have taken no action
I had an MRI scan that confirmed the rupture
I had an MRI scan that did not confirm the rupture
I had a 2nd high resolution ultrasound scan that confirmed the rupture
I had a 2nd high resolution ultrasound scan that did not confirm the rupture
I saw another plastic surgeon for a 2nd opinion
I have decided not to have surgery
I am planning to have surgery or already had surgery (please answer next two questions)
None of the Above (please explain why)
Current Progress,
0 of 8 answered