Patient Questionnaire
1. Are you concerned about your physical appearance?
Yes
No
2. Do you think about your appearance all the time and wish you could think about it less
Yes
No
3. Please list the body areas you not like:
4. How many plastic surgeons have you seen?
5. Have you had plastic surgery before?
6. If you have had plastic surgery before, please list the procedures:
7. Were you satisfied with your prior surgeries?
8. Would you say one of your main concerns is being too thin? Or overweight?
9. How has this this problem with how you look affected your life?
10. Are you often upset about how you look?
Yes
No
11. Has it often gotten in the way of your social and dating life?
Yes
No
If yes please describe:
12. Has it caused you any problems with school or work?
Yes
No
If yes please describe:
13. Are there things you avoid because of how you look?
Yes
No
If yes please describe:
14. On an average day, how much time do you usually spend thinking about how you look?
Less than 1 hour a day
1-3 hours a day
More than 3 hours a day
Submit
Should be Empty: