Wondering if your symptoms might be linked to your breast implants? This questionnaire helps you explore common signs reported by people considering explant surgery, from fatigue and brain fog to joint pain and hormone shifts. It's designed to guide self-reflection and support informed conversations with your care team.
How to Use It
Download and print the PDF, then work through it section by section. For each symptom: if you don't experience it, leave it blank; if you do, tick the box that matches the severity: mild, moderate, or severe. Bring the completed form to your appointment so your clinician can see the full picture at a glance.
What It Covers
The questionnaire walks through the whole body, with sections for:
- General: sleep, temperature regulation, fatigue, flushing
- Head, eyes & ears: headaches, vision and hearing changes, ringing
- Musculoskeletal: joint and muscle pain, stiffness, cramps, spasms
- Mood & nerves: brain fog, anxiety, dizziness, numbness, tremor
- Cardiovascular: palpitations, blood pressure, chest symptoms
- Urinary: urgency, incontinence, infection
- Digestion: bloating, reflux, food intolerances, bowel changes
- Eating: appetite, cravings, weight changes
- Respiratory: congestion, cough, shortness of breath, sinus issues
- Nails, lymph nodes & skin: texture changes, swelling, rashes, dryness, itching
- Female reproductive: menstrual, premenstrual, and hormonal symptoms