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9
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1
Name
First Name
Last Name
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2
Email
example@example.com
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3
Were you diagnosed with Breast Cancer and/or Had Breast Cyst?
YES
NO
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4
Did you have to undergo a mastectomy?
YES
NO
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5
What was removed?
One Breast
Both breast
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6
Have you undergone a reconstruction?
YES
NO
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7
Did you undergo skin grafting to replace the areola?
Did the surgeon replace nipple with skin from other parts of your body?
YES
NO
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8
Are you in remission?
YES
NO
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9
How long have you been cleared from doctor's orders?
3-6 months
8-10 months
1-2 years
Its been a very long time since my surgery.
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