Breast Implant Illness Survey Breast Implant Illness Survey Step 1 of 10 10% First Name* Last Name* Email* How long have you had breast implants?Less than 5 yearsBetween 5 and 10 yearsBetween 10 and 15 years15+ yearsAre you Before or After breast implant removal surgery at the time of completing this?*BeforeAfterIf you've had surgery, how long ago was your procedure? Please indicate which of the following symptoms you suffer from and the level of severity on a scale of 1-5Acne 1 (not at all) 2 3 4 5 (significant) Anxiety, depression and panic attacks 1 (not at all) 2 3 4 5 (significant) Chronic fatigue 1 (not at all) 2 3 4 5 (significant) Bowel and bladder issues 1 (not at all) 2 3 4 5 (significant) Brain Fog 1 (not at all) 2 3 4 5 (significant) Autoimmune issues 1 (not at all) 2 3 4 5 (significant) Choking feeling 1 (not at all) 2 3 4 5 (significant) Chronic iflammation 1 (not at all) 2 3 4 5 (significant) Chronic sinusitis 1 (not at all) 2 3 4 5 (significant) Connective tissue disorder 1 (not at all) 2 3 4 5 (significant) Dark, puffy, inflamed eyes 1 (not at all) 2 3 4 5 (significant) Difficulty swallowing 1 (not at all) 2 3 4 5 (significant) Dry skin and hair 1 (not at all) 2 3 4 5 (significant) Constant dehydration 1 (not at all) 2 3 4 5 (significant) Fever/chills 1 (not at all) 2 3 4 5 (significant) Food intolerances 1 (not at all) 2 3 4 5 (significant) Hair loss 1 (not at all) 2 3 4 5 (significant) Headaches and tension 1 (not at all) 2 3 4 5 (significant) Heart palpitations 1 (not at all) 2 3 4 5 (significant) Hormonal issues 1 (not at all) 2 3 4 5 (significant) Insomnia 1 (not at all) 2 3 4 5 (significant) Joint, muscle and bone pain 1 (not at all) 2 3 4 5 (significant) Limb numbness 1 (not at all) 2 3 4 5 (significant) Memory loss 1 (not at all) 2 3 4 5 (significant) Muscle weakness 1 (not at all) 2 3 4 5 (significant) Nausea 1 (not at all) 2 3 4 5 (significant) Night sweats 1 (not at all) 2 3 4 5 (significant) Pins and needles 1 (not at all) 2 3 4 5 (significant) Poor body temperature regulation 1 (not at all) 2 3 4 5 (significant) Poor concentration 1 (not at all) 2 3 4 5 (significant) Recurring illness 1 (not at all) 2 3 4 5 (significant) Ringing in ears 1 (not at all) 2 3 4 5 (significant) Sensitivity to light and sound 1 (not at all) 2 3 4 5 (significant) Sharp pains in breasts and down arms 1 (not at all) 2 3 4 5 (significant) Shortness of breath 1 (not at all) 2 3 4 5 (significant) Skin rashes ad sensitivity 1 (not at all) 2 3 4 5 (significant) Slow healing 1 (not at all) 2 3 4 5 (significant) Stomach pain 1 (not at all) 2 3 4 5 (significant) Unexplained weight gain or loss 1 (not at all) 2 3 4 5 (significant) Vertigo 1 (not at all) 2 3 4 5 (significant) Vision disturbances 1 (not at all) 2 3 4 5 (significant) Yeast and bacterial infections 1 (not at all) 2 3 4 5 (significant) CAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Δ