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Menu
Home
Procedures
Breast
Breast Enlargement
Breast Lifts
Breast Reduction
Breast Asymmetry Correction
Breast Reconstruction
Breast Revision
Inverted Nipple Correction
Male Breast Reduction
Safer Breast Lift Surgery
Body
Tummy Tuck Abdominoplasty & Mummy Makeovers
Arm Lift
Brazilian Butt Lift
Labiaplasty
Liposuction
Body Lifts
Surgery after Weight Loss
Face
Brow Lift & Eyelid Surgery (Blepharoplasty)
Facelift
Otoplasty – Ear Surgery
Non-Surgical
Lip Enhancement
Treatment of Lines and Wrinkles
Excessive Sweat Management
Migraine Management
Skin Peels
Complimentary Skin Assessment
Cosmetic Advisory Service
Skin Care Products
General
Scar Revision
Skin Cancer Surgery
Gallery
GC Non-Surgical Symposium
Accolades
News
Bookings
For Patients
Patient Registration
Implant Removal – Pre Explant
Implant Removal – Post Explant
Breast Implant Removal Webinars
Contact Us
Breast Implant Removal – Post-Explant Form
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Breast Implant Removal – Post-Explant Form
Self-Reported Symptoms in Women Baseline Questionnaire
Name
*
Patient ID
*
Date
*
Date Format: MM slash DD slash YYYY
Do you have any allergies to
Medicines
Pollen
Dust
Tree Nuts
Shellfish/Fish
Mould
Milk/Dairy
Wheat
Peanuts
Gluten
Soy
Eggs
Other
Please list
Menopausal
Pre-menopausal
Peri-menopausal
Post-menopausal
Please list any prescribed medications you have taken in the last 3 months
Are you taking any prescribed Hormone Replacement Therapy
*
Yes
No
Are you taking any over the counter supplements
*
Yes
No
Please list
Do you have any amalgam dental fillings
*
Yes
No
Do you have any of the following symptoms: (check all that apply)
Headaches
Low Libido
Abdominal pain
Hair loss
Dry mouth
Dry eyes
Fatigue
Weight gain
Memory issues
Joint pain
Heartburn
Diarrhoea
Cold intolerance
Brain fog
Insomnia
Anxiety
Weight loss
Depression
Irregular heartbeat
Hair loss
Muscle pain/weakness
Numbness/tingling in extremities
Rash
None of the above
Other
Please list
Have you been diagnosed with any of the following
Fibromyalgia
Hashimoto’s Thyroiditis
Irritable Bowel Disease
Endocrine Dysfunction
Graves’ Disease
Inflammatory Bowel Disease
Hypothyroidism
Lyme Disease
Vitamin D deficiency
None of the above
Other
Other
History of other medical conditions unrelated to the symptoms listed above?
*
Yes
No
Please list
Have you seen other physicians regarding your symptom
Yes
No
Not applicable
Primary Care
Neurologist
Infectious Disease
Integrative Wellness
Rheumatologist
Other
Please list
Family history of auto-immune or connective tissue disease?
*
Yes
No
Please list and state relationship to you
Have you experienced any of the following personal losses in the past year: (Check all that apply)
None
Death of a loved one
Divorce
Son/Daughter moved far away
Job loss
Loss of reputation/status
Loss of financial security
Other
Please list
Reason implants were placed
Augmentation
Revision Augmentation
Reconstruction
Date that your current implants were placed
(If you do not know exact year, please provide year)
Implant manufacture
Allergan
Mentor
Unknown
Other
Please list
Are your current implants
Saline-filled
Silicone-filled
Textured
Smooth
Above the muscle
Below the muscle
Unknown
If you have had other implants in the past complete the following information
(If you have no additional breast implant history, please skip)
First breast augmentation
Date year (estimate acceptable)
Date Format: MM slash DD slash YYYY
First breast augmentation
Silicone
Saline
Unknown
Textured
Smooth
Unknown
History of complications?
Second breast augmentation
Date year (estimate acceptable)
Date Format: MM slash DD slash YYYY
Second breast augmentation
Silicone
Saline
Unknown
Textured
Smooth
Unknown
History of complications?
Third breast augmentation
Date year (estimate acceptable)
Date Format: MM slash DD slash YYYY
Third breast augmentation
Silicone
Saline
Unknown
Textured
Smooth
Unknown
History of complications?
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