Breast Implant Survey

Age:
Height: 
Weight: 
Location of Incision  Under Breast Nipple Armpit Belly Button
Are you happy with this location?
Yes No Not Sure
Implant cc size?: 
Was your main concern size, a natural look, or a combination of the two?
Size Natural Look A combination of size and a natural look
Before size: 
After size: 
I  Wish I had gone bigger Wish I had gone smaller Like my new size
How long have you had your implants?: 
Do you have Saline or Silicone? Saline Silicone
Round or Anatomical? Round Anatomical
Why did you choose this shape and are you happy with it?

Implant Brand? 
Are your implants under or over the muscle? Under Over
Are you happy with the placement?
Yes No Not Sure
Did you bruise after surgery? Yes No
Any stretch marks resulting from the surgery? Yes No
Textured or Smooth? Textured Smooth
Did you massage your implants? Yes No
If yes, when did you start and how often?:

How would you rate the pain:  1-Bearable 2-I've had worse 3-Somewhat Painful 4-Painful 5 Very Painful 6-Felt like I've been hit by a truck
Do you have trouble sleeping with the implants? Yes No
How soon did you notice the implants were settling or softening?

Have you noticed any ripples? Yes No
If so, explain:

Overall, are you happy with your implants? Yes No
Do you have any permanent changes in nipple sensation?:

If you have had a child after having implants, did they change in any way?

Did you have any complications?:

Comments about your surgeon? 

Would you recommend your surgeon?: Yes No
Surgeon's Name? 

Surgeon's city & state? 

Your Name: 
Your Email: 
May we add your comments about your doctor to our web site? Yes No
If yes, may we use your first name and/or email? Yes First Name Only Email Only No