TRAINING ONLY: Post-Scan Survey - No Suspected Rupture (5A)

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

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.

Question Title

1. As your ultrasound scan did not show an implant rupture, which of the statements below apply to you? (check all that apply)

I feel relieved

I now have peace of mind about my implants

I am concerned the scan may be false negative (looks intact on scan, but is ruptured)

I am concerned about possible silent rupture in the future

Question Title

2. Going forward, would you get in-office ultrasound scans regularly to screen for silent rupture?

Every 3 months

Every 6 months

Every year

Every 2 years

Would not do scans regularly to screen for silent rupture

Question Title

3. 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)

Silicone gel – natural feel, need MRI or ultrasound scans to detect silent rupture

Structured – natural feel, look in mirror to detect rupture so no scans, saline-filled

Saline – less natural feel, look in mirror to detect rupture so no scans

I would not choose to get breast implants