External Breast Prosthesis Survey
This survey is open to individuals who currently wear an external breast prosthesis or have worn an external breast prosthesis in the past.
For any further comments, please use the section at the end.
All participants will remain anonymous.
* Required
1. How often do you wear your breast prosthesis?
*
Choose
Daily
More than once a week
More than once a month
More than once a year
Once a year or less
Never
2. How long have you been wearing a breast prosthesis?
*
Choose
Less than 6 months
6-11 months
1-5 years
More than 5 years
I do not wear a breast prosthesis anymore
3. How often do you buy a new breast prosthesis?
*
Choose
I still have my first breast prosthesis
Once a year
Once every 2 years
Once every 3 years
Once every 4 years
Once every 5 years or more
I no longer wear a prosthesis
4. Which company/companies did you buy your breast prosthesis from?
*
Your answer
5. Why did you choose to buy your breast prosthesis from this company/companies?
*
Your answer
6. If you no longer wear a breast prosthesis, what is the reason for the abandonment of your breast prosthesis?
If you do wear a breast prosthesis please do not answer this question. If you no longer wear your breast prosthesis please move to question 27 once answering this question.
Your answer
7. Do you change the types of clothes you wear because of your breast prosthesis?
Choose
Yes
No
8. Do you have a selection of breast prostheses for different clothing?
Choose
Yes
No
9. Do you wear non mastectomy bras?
Choose
Yes
No
10. Do you own different types of breast prostheses? If yes, please state how they differ in the comment section at the end of the survey.
Choose
Yes
No
11. Do you wear a breast prosthesis that adheres to your skin or sits in a bra?
Choose
Adheres to skin
Sits in a bra
Other
12. Would you wear a breast prosthesis that was not skin coloured? (Eg. blue)
Choose
Yes
No
Maybe
13. How important is it that your breast prosthesis is not visible through your clothing?
Not important at all
1
2
3
4
5
Very important
Clear selection
14. How important is it that your breast prosthesis is lightweight?
Not important at all
1
2
3
4
5
Very important
Clear selection
15. How important is it that the colour of your breast prosthesis matches your skin tone?
Not important at all
1
2
3
4
5
Very important
Clear selection
16. How important is it that your breast prosthesis has a nipple?
Not important at all
1
2
3
4
5
Very important
Clear selection
17. How important is it that your breast prosthesis feels like a natural breast?
Not important at all
1
2
3
4
5
Very important
Clear selection
18. How important is it that your breast prosthesis matches your natural breast? (single mastectomy only)
Please do not answer this question if you have had a double mastectomy.
Not important at all
1
2
3
4
5
Very important
Clear selection
19. How important is it that your breast prosthesis matches your natural breast/s pre surgery?
Not important at all
1
2
3
4
5
Very important
Clear selection
20. How important is the comfort of your breast prosthesis?
Not important at all
1
2
3
4
5
Very important
Clear selection
21. How important is it that the temperature of your breast prosthesis is similar to your body temperature?
Not important at all
1
2
3
4
5
Very important
Clear selection
22. How important is it to be able to wear your breast prosthesis while exercising?
Not important at all
1
2
3
4
5
Very important
Clear selection
23. How important is it that your breast prosthesis does not cause you to sweat?
Not important at all
1
2
3
4
5
Very important
Clear selection
24. How important is it to be able to wear a non mastectomy bra?
Very important
1
2
3
4
5
Not important at all
Clear selection
25. What do you like about your breast prosthesis?
Your answer
26. What do you dislike about your breast prosthesis?
Your answer
27. What would you like to see improved in breast prostheses?
*
Your answer
28. Please make any further comments below
Your answer
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Report Abuse
-
Terms of Service
-
Privacy Policy
Forms
