• Busting Out of Silence Medical Survey

    Anonymous Medical Campaign Questionnaire for Online Reporting
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  • Hosted on: www.thebionicbras.com

    Campaign Founder: Dr. Pamela McQueer, ND, CHS, CHNP

    Founder, Bionic Sports USA | Creator of The Bionic Movement | Inventor of the Bionic Bra

    This questionnaire is for athletes reporting previous or current breast sports-related injuries. The purpose is to collect anonymous information that can help improve awareness, reporting, prevention, research, and future safety standards in sports.

  • IF YOU ARE UNDER THE AGE OF 18, A PARENT OR LEGAL GUARDIAN MUST COMPLETE OR APPROVE THIS FORM.

  • Athlete Medical Questionnaire

  • Parent or guardian approval if under 18
  • Level you play or did play

  • Injury Details and Symptoms

  • Ever experienced a sports-related breast injury?*
  • About how old were you when the injury first happened?
  • Which breast or chest area was affected most?
  • How did the injury happen?
  • What symptoms did you notice?

  • Reporting and Care

  • Did you tell anyone about the injury at the time?
  • If you did not report it, why not?
  • Did you receive medical care?
  • Were any tests or imaging done?
  • Have you ever been told by a doctor that you had any of the following?

  • Current Impact and Awareness

  • Are you still having symptoms now?*
  • Did the injury affect your sports participation?*
  • At the time of injury, what breast or chest protection were you wearing?*
  • Has anyone ever educated you about breast injuries in sports?*
  • In your opinion, how important is it to report breast sports-related injuries?*
  • May anonymous quotes from your responses be used for awareness, education, or campaign materials?*
  • Should be Empty: