Breast Implant Examination Checklist Form
Complete this checklist to document findings and observations during a breast implant follow-up examination.
Date of Examination
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Implant Side
*
Left
Right
Bilateral
Type of Implant
*
Please Select
Saline
Silicone
Other
Date of Implantation (Year)
*
Reason for Follow-Up
*
Routine check
Reported symptoms
Post-surgical review
Other
Current Symptoms
*
Pain
Swelling
Redness
Firmness
Asymmetry
None
Other
Physical Examination Findings
*
Normal
Capsular contracture
Implant rupture suspected
Seroma
Skin changes
Other
Imaging Performed
*
None
Ultrasound
MRI
Mammography
Other
Complications Noted
*
None
Rupture
Infection
Capsular contracture
Seroma
Other
Additional Notes / Recommendations
Submit Checklist
Should be Empty: