ABC Massage Form Survey

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American Breast Care wants to know about your wear experience with The Massage Form. Tell us what you think.

We would love to hear from you!

By completing this simple survey, you enter a semi-annual drawing for your collection of ABC bras (a $300 Value!)

What is/are the dates of your mastectomy surgery?
What physical problems have you had since your surgery (Either temporary or permanent)?
Do you often have swelling in your chest wall and/or surgery area?	Yes No
If yes, how often is the swelling a problem for you? (Please check selection)	N/A Daily Weekly Monthly Every 2 - 3 Months Every 4 - 8 Months Every 8 - 12 Months
Do you have swelling in your hand and/or arm on the surgery side?	Yes No
If yes, how often is the swelling a problem for you? (Please check selection)	N/A Daily Weekly Monthly Every 2 - 3 Months Every 4 - 8 Months Every 8 - 12 Months
Do you have swelling from breast cancer treatment for which you seek regular therapy?	Yes No
How many hours a day on average do you wear The Massage Form(s)?	2 - 4 Hours 4 - 8 Hours 6 - 8 Hours 8 - 10 Hours More than 10 Hours
Do you find The Massage Form easy to wear?	Yes No
After wearing for a length of time, did you find The Massage Form was of any benefit?	Yes No
Please explain your above answer in as much detail as possible.
Have you or will you file for insurance reimbursement for this form?	Yes No
Compared to other breast forms you have worn, wearing the massage breast form is:	Extremely Comfortable Comfortable Fairly Comfortable Uncomfortable
Please provide your contact information. Your information will only be used to inform you of contest results should you win. Thank you for your feedback!	Name Email Daytime Phone
Reset and Begin Again	Submit