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)

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* 2. Subject Initials (2 characters)

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* 3. Confidential Subject ID (3 Numbers)

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* 4. Interviewer Last Name

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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)

0 of 8 answered
 

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