This self assessment for BII will help to determine if you would benefit from a consultation with Dr. Whitfield and his BII team. Dr. Whitfield sees patients from all over the world. His BII recovery program includes top of the line lab testing, innovative technology and devices, BII curated supplements and more all in his Breast Implant Illness & Explant Clinic, headquartered in Austin,Texas.

How long have you had breast implants? *

Did you begin experiencing increasing amounts of fatigue after getting your breast implants?

Yes

What symptoms have you experienced since getting breast implants? (Click all that apply)

What type of breast implants do you have?

Saline

Silicone

Textured

I'm not sure

Who is the manufacturer of your Implants? *

How long was your post-implant surgery recovery?

I was back to myself in 6 weeks

My recovery to full function was 6 - 12 months

My breast implants still give me problems

When did you start feeling “off” or begin noticing symptoms after getting your breast implants?

How many breast augmentation surgeries have you had?

Only one, the original surgery.

Two, either due to size change, rupture or capsular contracture.

Three or more, due to complications or personal choice.

Have you had an accident or injury to the breast? Fallen, car accident, exercise related injury?

Yes

Have you had blood work and labs done or seen more than one doctor for your symptoms?

Yes and my blood work always comes back fine even though I feel like something is wrong.

My blood work is not ok but doctors still do not know what is wrong.

I have seen countless doctors, specialists and still have no answers.

Have you suspected that your breast implants could be causing your health problems but doctors have dismissed your concerns?

Yes and no one will listen to me.

I told my doctor but they aren’t convinced my implants are the issue.

My doctor agrees that my health issues may be related to my breast implants.

Have you had your hormone levels checked?

Yes I have had my hormones checked and they are great.

Yes I have had my hormones checked and they are out of balance.

Yes, I have my hormones regularly checked and I am on hormone replacement therapy.

I have not had my hormones checked in a year or more.

Have you been exposed to mold?

Yes I lived or visited a house with visible mold.

No, I have never been exposed to mold.

I do not know if I have ever been exposed to mold.

Have you moved into a different home since getting your breast implants?

Yes I moved into a different home after getting breast implants.

No, I have always lived in the same home.

When was your home built?

My home is new or was built within the last 5-10 years.

My home is 10-20 years old.

My home is 20-30 years old.

My home was built over 40 years ago.

Have you lived in a home as it was being renovated, or do you work as a real estate agent or designer and regularly visit homes during remodeling?

Yes I have lived in a home as it was being renovated.

I am a real estate agent or designer and visit homes being remodeled

I have remodeled my home but did not live there or visit it during remodel.

I visited my home as it was being remodeled and did not wear a N-95 mask.

No, I live in a home that has never been remodeled since I moved in.

How do YOU Feel - Breast Implant Illness unknowingly plagues millions of women every year. Sometimes as soon as a few months after implant surgery, women report feelings of fatigue, depression, brain fog and memory loss or generally feeling unwell.

How many hours of sleep do you get at night?

I don’t sleep well most nights

6-8 hours off and on

I get about 7 hours, but wake up at least once

I sleep really well, 6-8 hours nightly

Most days, how is your energy level?

I feel energized and ready for the day

My energy feels fine in the morning, then I crash mid afternoon

I feel extremely fatigued and drained most of the day

My energy levels go up and down throughout the week

Most days, how is your memory?

I feel sharp, memory is not an issue for me

My short term memory sometimes is a problem

I write a lot of notes for myself so I can remember and stay organized

A lot of my memories from a few years ago are very foggy

Most days, how is your mood?

I have been very snappy and impatient lately

I have a mixture of anxiety and depression

My mood is up and down and sometimes uncontrollable

I feel like I’m fairly pleasant most days

Most days, how is your sex drive?

I enjoy sex and have a healthy libido

I enjoy sex but I am not in the mood all of the times

I don’t desire sex all the time, sometimes I’m happy when my partner does not initiate

I don’t desire sex at all

Since having breast implants, what areas of your life have dramatically changed in a way that has negatively impacted your life. Check all that apply

How is your Gut? Check all that apply

I struggle with constipation.

I get diarrhea often.

I switch between constipation and diarrhea.

I am always bloated after eating.

Everything gives me gas or stomach pain.

Your Lifestyle: Your nutrition and fitness can severely affect surgical outcomes. Let’s assess your lifestyle and personal habits, be as honest as you can, there is no judgment here.

How would you rate your fitness and activity level?

I am a gym rat, I have to go at least 5 times a week

I go to the gym a few times a week

I workout a couple times a month

I used to workout but cannot at all anymore

How would you rate your strength and physical fitness?

I am super strong and feel great

I feel like I’m fit and I’m not out of breath walking up stairs

I know I need to get in better shape and want to get started

I feel weak and drained

How many times a day do you eat?

3-6 times a day

3 times a day

2 a day

I’m lucky if I get in one meal a day

How much water do you consume?

64 ounces or more

48 ounces or more

24 ounces of water or less

Not a daily water consumer

How do you store your food?

Glass containers

Plastic containers

Original product packaging

Mixture of all three

How would you categorize your eating lifestyle? Check all that apply

Do you have food sensitivities?

Yes, certain foods bother me.

I have high sensitivities to specific foods and have to be careful about what I eat.

I have inflammation and feel puffy but I’m not sure if I have food sensitivities.

I have no sensitivities to any food.

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Your Breast Implant Illness Self-Assessment is now complete. Check your inbox shortly for your report!

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