Breast Implant Illness Quick Assessment
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First Name *
Last Name *
Phone Number *
Email *
Current Back Size *
Current Bra Cup Size *
Current Implant Filling *
Current Implant Size *

Please score each of the following BII symptoms from 0 (none) through 10 (severe):

 *
0
1
3
4
5
6
7
8
9
10
Fatigue
Body Odor
Hair Loss
Cognitive Dysfunction
Weight Problems
Frequent Urination
Joint Pain/Aches
Rash/Dry Skin
Vertigo
Headaches
Chest Discomfort
Chronic Pain
Poor Sleep/Insomnia
Anxiety/Depression/Panic Attacks
Pain/Burning Around Implant and/or Underarm
Neurological Abnormalities
Muscle Pain/Weakness
Endocrine Dysfunction
Hashimoto's
Inflammation
Reflux
Ear Ringing
Irregular Heartbeat
Low Libido
Fever/Night Sweats
Fungal Infections
Raynaud’s Syndrome
Intolerant to Heat/Cold
Cold/Discolored Limbs/Hands/Feet
Symptoms of or diagnosis fibromyalgia
Numbness/Tingling in upper/lower extremities
Gastrointestinal and digestive issues such as IBS, acid reflux, GERD, Gastritis
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