Dr. Kevin Brenner's Breast Implant Illness Quick Assessment
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Email *
First Name *
Last Name *
Phone Number *
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):

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

 *

Acid 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

 *
A copy of your responses will be emailed to the address you provided.
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